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In the reconstruction of conchal remnant–type microtia, the incisions are modi ed
to make maximal use of the additional skin that is available.The framework is also
modi ed and spliced into the usable portions of the cartilage remnant (although the
concha, even if well formed, will usually need expansion or partial resection).
Firmin’s modified incisions and flap designs for type 2 and type 3 deformities6
(small and large conchal remnant microtia, respectively) seem to make better use of
the available skin than those used by Nagata.3,4 In these cases efforts to maintain the
subcutaneous pedicle to the upper flap may limit optimal redraping of the skin
over the framework and sacri ce skin that is better maintained for coverage of the
postauricular surface of the framework (see pp. 774 and 775).
SECOND-STAGE RECONSTRUCTION
Second-stage reconstruction varies according to whether one follows the model of
Nagata3,4 and Firmin6 or the techniques described by Brent.1,2,11 Because I prefer
the former, I will discuss it rst, but I will also review the latter approach. Second-
stage reconstruction is generally carried out 3 to 4 months after the rst stage. Un-
like rst-stage reconstruction, the second stage is generally performed as an outpa-
tient procedure. For some patients this stage will complete the reconstruction.
The second stage, as we carry it out today, having included the tragal construction
and lobule rotation in the rst stage, involves elevation of the reconstructed ear and
creation of the postauricular sulcus.The innovation introduced by Nagata3,4 was to
add a banked cartilage graft to the underside of the elevated framework to help
project the ear outward from the head, minimizing or eliminating the need to carry
out a setback of the contralateral ear for symmetry.The graft essentially mimics the
posterior conchal wall (see pp. 768 and 769).
With the ear elevated and the graft positioned beneath the framework, the bare
cartilage needs the vascular coverage of either a temporoparietal fascial ap or a
postauricular fascial ap and skin graft (see p. 768).The skin graft is typically a split-
thickness graft (or the ultrathin graft described by Nagata) and is harvested from the
adjacent scalp. The graft is sutured in place with 5-0 chromic catgut sutures with
multiple “quilting sutures” of 4-0 chromic catgut placed meticulously to prevent
any possibility of tenting of the graft from the multiple contours of the posterior
surface of the ear and mastoid region. After this approach, a well-packed Xeroform
gauze dressing covered with uffy gauze and a head wrap is all that is required. A
“tie-over” dressing is not needed.The dressing is typically left in place for 1 week.
This approach allows for better elevation of the reconstructed ear, a better formed
postauricular sulcus, and improved ear symmetry from both frontal and posterior
views (see p. 769).

For patients who have undergone reconstruction according to the Brent model, the
second stage involves rotation of the lobule, conchal excavation, and construction
of the tragus with a composite graft from the contralateral concha.The lobule is re-
leased and can be dissected with a pocket between the layers that allows the lobule
to be “ tted over the inferior pole of the cartilage framework” (see pp. 770-773).
The tragus is created by backing an anteriorly based skin ap with the composite
graft, creating a shadow behind this construct to suggest the presence of an exter-
nal auditory meatus and canal. A full-thickness skin graft may also be used, attached
to the composite graft to gain additional lining in the area of the pseudomeatus (see
p. 771).
THIRD-STAGE RECONSTRUCTION
Following the Brent model, the third stage of reconstruction involves elevation of
the reconstructed ear, initially described without additional cartilage block for
framework projection, but now on occasion with a similar approach to the Nagata
technique for the second-stage surgery. Additional third-stage procedures may in-
clude further re nement of the framework details, additional release of the ele-
vated ear in cases where split-thickness skin graft contracture has overcome part of
the initial elevation (despite the added framework support), and enhancement of
the tragal projection, where the prominence or underlying shadow is inadequate.
This latter condition is more likely to exist in cases where the reconstruction was
done at an earlier age than 10 years and there was inadequate cartilage or cartilage
strength to maintain the tragal projection.
As an alternative to the technique of tragal construction described by Brent and
shown in my modi cation (see pp. 770 and 771), I have found that the degree of
tragal projection, delicate anatomy, and ability to create and maintain the “hollow”
or shadow behind it is made signi cantly easier with the use of an alternative ap-
proach. In reoperative surgery when the tragus was not reconstructed initially, this
involves “turning over” a tragal-shaped ap, based conchally so that the undersur-
face is ap skin rather than skin graft.The composite graft is then placed on the up-
per surface with the skin facing outward. The cheek skin is then advanced to the
tragal base.The angle or plane of projection of the tragus is adjusted by xation of
the cartilaginous part of the composite graft to adjacent costocartilage framework.
Given the donor site of the graft, the color match is excellent and there is no ten-
dency for contracture of the skin of the concha or posterior surface of the tragus
as it is lined by a ap rather than graft.This approach creates a comparable shadow
to the area of the pseudomeatus, as can be gained with either initial placement of
the cartilage as part of the framework or by the Brent technique.
Any additional adjustments of the lobule, helical rim, and so forth may often be car-
ried out at this procedure as well, or they may be left for a nal touch-up under lo-
cal anesthesia after a period that is long enough to allow all the scars to mature and
tissues to settle into the cartilaginous hollows and contours.
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An alternative method of tragal reconstruction is demonstrated in a patient in
whom the initial framework was not designed to include the tragus. In this case, the
tragal ap is elevated with the base toward the concha and the composite graft is
placed onto the lateral surface (outer surface) of the ap, leaving the concha fully
lined with ap skin.The thin natural tragal projection and thickness are the result
of this approach;in addition, the diminutive lobule is “plumped” with a dermal fat
graft.
RECONSTRUCTION OF THE DYSTOPIC AURICLE
One of the most dif cult problems encountered in the reconstruction of the mi-
crotic ear is dealing with a microtic vestige that is markedly displaced from a sym-
metrical position with the other side. This displacement is a result of the marked
degree of both skeletal and soft tissue de ciency associated with the more signi -
cant degrees of hemifacial microsomia (see pp. 762, 779-781, 783, and 785-786). In
these cases, both of the procedures are required to place the nal reconstruction in
a symmetrical position, and the issues of timing of the auricular and mandibular re-
construction are still to be resolved. The approach described here takes these fac-
tors into account and allows coordinated treatment of both auricular and mandibu-
lar deformities.9,10

Although an in-depth discussion of the lobular transposition, framework modi ca-
tions, and sequencing of the auricular reconstruction with mandibular distraction,
skeletal augmentation, and other craniofacial-related techniques is beyond the scope
of this chapter, issues of positioning the reconstructed ear and use of fascial aps for
coverage of the cartilage framework pertain directly to reoperation for a previously
unsuccessful result. In the former case it is often necessary to provide skin graft
over fascial ap coverage of the framework because the symmetrically positioned
ear is often over hair-bearing skin;in the latter case scarring from previous surgery
may make the adjacent skin unusable.
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Reconstruction in the face of severe hemifacial microsomia requires initial reposi-
tioning of the vestige, then later augmentation of the cartilage framework to com-
pensate for the underlying skeletal de ciency. Skeletal (particularly temporal bone)
and soft tissue de ciency is evident superior to the dystopic vestige in this 5-year-
old child. An illustration of the x-ray lm template taken from the normal side
marks the position of the planned symmetrical reconstruction.

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The position of the vestige is shown in relation to the proposed reconstruction, as
well as the position of the super cial temporal artery (STA), postauricular artery
(PA), and occipital artery (OCC). In particular, note how far anterior the STA is to
the planned nal reconstruction. This requires a wide temporoparietal fascial ap
based on the STA and PA, and on occasion a third unnamed vessel may be pre-
served centrally in the ap.The framework is augmented with an additional carti-
lage block on its undersurface to ll the underlying skeletal defect and, as illus-
trated in the drawing, project the framework outward in equal projection to the
opposite normal side.

The framework is xed in place and covered with the temporoparietal fascial ap
(TPFF) and split-thickness skin graft. The nished reconstruction is illustrated a
year after completion of the reconstruction.
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FASCIAL FLAPS IN EAR RECONSTRUCTION
Although the use of fascial aps in reconstruction of microtia is typically reserved
for patients with atypical anatomy, such as auricular dystopia, aps may also be re-
quired in the salvage of complications of microtia reconstruction and treatment of
acquired deformities10,12-16 (see pp. 779-781 and 793-794). One must remember
that the anatomy of the STA, PA, and OCC is altered to varying degrees depend-
ing on the extent of hemifacial microsomia. As part of the preoperative planning,
they should be mapped with a Doppler probe. The TPFF is the most commonly
used of the fascial aps in complex ear reconstruction. It is equally versatile in sec-
ondary reconstruction.14-16 The ap is supplied by both the STA and PA and al-
though the ap is typically elevated on the STA alone, whenever possible both ves-
sels should be included to minimize risk of partial flap necrosis (see p. 790).
Although the TPFF has also been used as a random ap by Brent and Byrd,13 this
is generally not recommended in reconstruction of the congenital ear deformity.
The postauricular fascial ap (PFF) supplied by the PA and OCC is a continuation
of the TPFF (super cial temporal fascia).The deep temporal fascial ap is supplied
by the middle temporal artery, which arises from the STA.17,18 It may also include
a branch of the PA. Both of these aps may play a role in secondary or reoperative
ear surgery, particularly as salvage after failure of the TPFF. Although the former is
quite effective in coverage of small areas of skin or ap loss in the middle and lower
thirds of the ear (even, on occasion, in preference to the TPFF), these other aps are
used relatively rarely.
FIRST-STAGE TRANSPOSITION OF THE
MICROTIC VESTIGE
Given the triplanar malposition of the dystopic remnant,9,10 it is often necessary to
move the remnant as close as possible to its ultimate position before the stage when
the cartilage framework will be placed.This will help to preserve the blood supply
to the remnant and allow further positioning of the remnant at the time of the for-
mal rst-stage reconstruction when the framework is placed either beneath the ad-
jacent skin (if adequate non–hair-bearing skin is available) or beneath a TPFF.The
movement of the remnant varies depending on whether there is a patent auditory
meatus and canal associated with it.
The reconstruction should begin with the initial assessment of the patient and a de-
termination of the position of the auricular remnant in relation to the ideal sym-
metrical position for the reconstructed ear. An x-ray lm or celluloid sheet is ideal
for this evaluation (see pp. 763 and 779). Unlike the more “typical” cases of micro-
tia discussed earlier, where the remnant tends to be anterosuperior in position, these

cases are typi ed by the anteroinferior position of the remnant. The initial pos-
terosuperior movement of the vestige may be carried out in early childhood, years
before the main reconstruction. Performing this part of the procedure early has the
considerable bene t of getting the remnant to a location closer to “normal” and
makes the overall deformity less conspicuous. This may have signi cant psycho-
logical bene ts for the affected child during the years of waiting for the formal re-
construction.
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The most common method of repositioning the vestige is illustrated using a Z-
plasty–like transposition of the vestige. Typically, as shown, the lobule may still lie
slightly lower than its ideal position and will be moved further into a symmetrical
position when the framework is placed. Again the x-ray lm template is used to
demonstrate the position of the vestige (see p. 763).
The remnant is most commonly transposed with a Z-plasty–type maneuver but
can also be advanced posteriorly on the leading edge of a cheek ap or as an island
ap. As the remnant and adjacent ap interchange position, there is a relative gain
in skin anteriorly widening the distance between the ear and the lateral canthus and
other central facial landmarks. In some patients the dystopic remnant includes the
meatus and displaced canal (this is common in more severe cases of hemifacial mi-
crosomia). The extent of movement is dependent on the length of the canal and
complexity of the adjacent anatomy (particularly the facial nerve). A CT scan or
MRI may give some preoperative insight into the course of the canal and nerve.
The cartilaginous canal is not separated from its connection with the bony canal
but can still pivot and move on it. In addition to identifying and protecting the fa-
cial nerve, one should also determine the course of the super cial temporal and
postauricular arteries and protect them as vascular pedicles for the future tem-
poroparietal fascial ap.

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SECOND-STAGE PLACEMENT OF THE
AUGMENTED AURICULAR FRAMEWORK AND
COVERAGE WITH THE TEMPOROPARIETAL
FASCIAL FLAP
FRAMEWORK CONSTRUCTION
The framework construction must be modi ed in these cases to make up for the
fact that the framework will sit on a hypoplastic base. The costal cartilage frame-
work is carved in the same manner as described previously, but then it is modi ed
by adding an infrastructure of cartilage, which is designed to compensate for the hy-
poplastic temporal bone and project the framework out into a symmetrical plane
with the normal opposite ear (see p. 780).This is most easily accomplished by com-
pleting the initial reconstruction, then positioning the framework in the appropri-
ate location, and measuring the amount of added projection necessary to place the
framework symmetrically in all planes. The additional block of cartilage is then
added beneath the framework, often using a T-shaped wedge to prevent it from
folding under (see p. 780).The placement of the framework is checked repeatedly
using the initial template, as well as by looking directly at the normal side (for com-
parison of positioning in the sagittal plane), to ensure a symmetrical nal position
for the reconstruction.
TEMPOROPARIETAL FASCIAL FLAP IN AURICULAR
DYSTOPIA R ECONSTRUCTION
Every effort should be made to include both the STA and PA in the ap.This will
require dissection of a wider than normal flap because the correctly positioned
dystopic reconstruction will be posterior and superior to the original position of
the remnant. The need for this is best understood by remembering that the STA,
like the associated remnant, has developed in a more anterior position in these hy-
poplastic cases. A larger than normal ap will also be required to provide enough
tissue to cover the augmented framework (see p. 780).
With the preceding point in mind, one must also recognize that during the eleva-
tion of the TPFF, the temporal branch of the facial nerve may cross directly beneath
the fascia as the anterior border of the ap is cut.The nerve is easily identi ed and
protected.The TPFF is covered with a split-thickness skin graft, which can be har-
vested from the adjacent scalp.

CORRECTION OF SKELETAL HYPOPLASIA IN THE
TREATMENT OF AURICULAR DYSTOPIA
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Staged Sequential Procedures for Ear Reconstruction
An alternative method of augmenting the de cient underlying skeleton in auric-
ular dystopia is illustrated here. The dystopic ear is prominent and appears to be
sheared off the side of the head as a result of hypoplasia of the underlying tempo-
ral bone.This bony defect is distinct from the mandibular hypoplasia and needs to
be addressed separately.The ear is freed from its dystopic position maintaining a vas-
cular pedicle and not dividing the cartilaginous from the bony canal. A posterior
vascular pedicle is maintained and the skin incision planned to allow transposition
of a skin ap below the elevated ear. In the presence of an intact canal, the cranial
graft is fashioned with a hook shape to wrap around the canal and a second graft
is taken (both through the hemicoronal incision) to create a cantilevered graft (as
illustrated).

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The ear is elevated and the graft xed in place with lag screws. At completion, the
ear is seen elevated and projected outward.The prominence will be corrected at a
subsequent procedure.
The three-dimensional CT scan demonstrates the slope of the temporal bone pre-
operatively and with the cantilevered graft visible 5 years postoperatively.The sym-
metry of the ears is evident after completion of the mandibular surgery.

The nal element in the treatment of this complex auricular deformity lies in cor-
rection of the hypoplastic temporal bone in cases of auricular dystopia unassociated
with microtia (an otherwise normal or prominent ear appearing to be sheared off
the side of the head) and in cases where the microtic ear has been successfully re-
constructed but the auricle is still in a dystopic position. In both of these instances,
the auricle can be freed suf ciently from the underlying skeletal and soft tissues to
allow placement of a cranial bone strut beneath it, as a cantilevered graft off the
temporal bone. The auricle or reconstructed ear is elevated at the subperiosteal
plane with the incision around the ear planned to ensure that a good vascular pedi-
cle remains. Part of the access for dissection can be obtained through a hemicoro-
nal incision used to harvest the cranial graft.When necessary, the dissection is car-
ried along the cartilaginous canal and the cranial graft is shaped as a supporting
hook around the canal.This bony augmentation is distinct from that accomplished
with either zygomatic arch/ temporomandibular joint reconstruction or correction
of the mandibular asymmetry.The bone graft is secured with either a lag screw or
microplate and screws. Late follow-up has shown maintenance of the cantilevered
graft, although the hook portion, which may temporarily compress the canal, will
resorb. Once the mandibular reconstruction is completed, the auricle will lie in a
position with symmetrical projection to the normal side.
INTEGRATION OF AURICULAR R ECONSTRUCTION
AND DISTRACTION O STEOGENESIS
Although it is beyond the scope of this chapter, it should be noted that current
staging of procedures for reconstruction of both the ear and mandible does allow
for some integration of procedures, at times minimizing the overall number of sur-
geries from beginning to completion of reconstruction. In more severe cases of
hemifacial microsomia, lengthening of the mandible may be accomplished fairly
early using distraction osteogenesis.10 Initial transposition of the dystopic vestige
may be carried out at the time of one of these early procedures, or at the time the
hardware is removed if that is required. Even if the skeletal reconstruction is in-
complete, the ear can still be reconstructed in symmetrical nal position by fol-
lowing the preceding principles.
TREATMENT OF MAJOR ACQUIRED AURICULAR DEFECTS
The principles gained from treatment of the major congenital ear deformities, es-
pecially microtia and the more severe forms of constricted ears, are directly trans-
latable to treatment of major acquired deformities of the ear. Although for some
surgeons acquired deformities are more a part of their practices than congenital
deformities, it is helpful to have a generalized way of classifying the acquired defor-
mities to select the optimal reconstructive technique.9,19 I have often thought that
the simplest way of doing this is to separate cases by both etiology and extent of soft
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tissue de ciency. Etiologic factors can be separated into the following: (1) trauma
of disease or iatrogenic injury;(2) burn and postchondritis deformity;and (3) trau-
matic (non–burn-related) auricular defects. The tissue requirements can then be
separated into cases with (1) skin and cartilage de ciency with minimal or “limited”
areas of scarring and (2) skin and cartilage deficiency with moderate-to-severe
scarring.
With the preceding in mind, it is possible to decide whether the defect can be re-
constructed with adjacent skin ap coverage or if a fascial ap and skin graft will be
needed for vascular coverage. It will also be possible to decide whether the cartilage
defect can be repaired using conchal cartilage (contralateral, ipsilateral, or both) or
if it will require a costal cartilage graft. One must also make a decision, in concert
with the patient, as to whether the reconstructive effort will be directed at restor-
ing the full vertical symmetrical height to the ear or whether a “normally shaped”
but smaller ear will be acceptable. The latter may be much easier to accomplish
and very acceptable in the proper setting. One must bear in mind that we rarely see
both ears at the same time so that vertical differences of as much as 1 cm may not
be that apparent. Each option must be carefully discussed with the patient recog-
nizing the pros and cons of different approaches.
Within the framework of a book on reoperative surgery there is insuf cient room
to devote to each of the many varied deformities; however, a few basic guidelines
can be added to the earlier discussion of acquired deformities that may help further
in selection of an “ideal” approach to the deformity. In general, if the quality of the
skin is reasonably good (limited scarring of both the ear remnant and adjacent skin),
a more delicate reconstruction can be accomplished using conchal cartilage grafts
than with costal cartilage, provided the defect is not too large. However, even if the
defect can be bridged with conchal cartilage grafts, a costal cartilage graft is prefer-
able if fascial ap coverage is required, as the conchal cartilage grafts are not sturdy
enough to resist the contracting forces of the healing fascial ap.The vascular sup-
ply of the ear and postauricular area is excellent, allowing for a multitude of differ-
ent ap designs. Although this sets the stage for considerable ingenuity in choice of
procedure, careful planning will allow the use of the larger more reliable aps.The
patient should understand that staged procedures are the rule more than the excep-
tion, even though following the initial “major” stage of reconstruction the subse-
quent procedures may be “minor” but necessary to obtain an optimal result.
R EOPERATIVE SURGERY OF THE AURICLE
As stated at the outset of this chapter, as demanding and to some extent “risky” as
the procedures required for reconstruction of major congenital and acquired ear de-
formities are, reoperation for a previously unsatisfactory result is even more de-
manding.16 The recipient bed is now scarred, the donor tissues are more limited,
and the expertise of the operating surgeon is even more critical.The skills required
tend to come from a combination of dealing with one’s own complications (hope-

fully few) as well as the referral of patients who have been treated elsewhere.These
patients have often been through multiple surgeries with little to show but a scarred
amorphous or malpositioned “ear” with signi cant surrounding scar, and in most
cases at least one side of the chest having served as a costal cartilage donor site.
For the sake of both treatment planning and discussion, it is best to apply the pre-
ceding general classi cation of acquired defects and separate patients presenting for
reoperation into those who had minimal efforts in the past to rearrange the ear
vestige, and therefore possibly limited scarring (and ample donor tissue) (see pp.
790 and 791), from those who have had multiple surgeries and a severely scarred
remnant with scars and skin grafts surrounding the ear vestige (see pp. 793 and
794). Although the former cases may have several available options, the latter will
require a totally new vascular envelope as well as new framework. In the latter cases
one must assess the presence of super cial temporal and postauricular arteries and
their extent over the needed territory for a fascial ap. Although the absence of
these vessels still leaves the option of microvascular transfer of contralateral TPFF,
this procedure may only be acceptable in a very select group of patients, again keep-
ing in mind that this group of patients has probably been through many unsatisfac-
tory surgeries before.
In addition to the quality of skin and vascularity of the TPFF territory, one must
consider the quality of donor costal cartilage, particularly in older patients. Al-
though the extent of calci cation of the donor costal cartilage varies from case to
case, most adult patients less than 40 years of age have enough exibility of the car-
tilage to still carve, shape, and splice together a reasonably thin framework.Whereas
those young or old with extensive calci cation can still have a framework carved
with power-driven burrs, there is at least some concern about the viability of the
cartilage when it is subjected to the heat of the burrs (even while carved under
water). The surgeon may also face signi cant problems with the cartilage fractur-
ing as it is spliced together.These issues may well affect how delicate a framework
and therefore nely detailed an auricle can be reconstructed, and must be consid-
ered and discussed with the patient.
SKIN AND CARTILAGE DEFICIENCY
WITH LIMITED SCARRING
Roughly speaking, if one is seeing more than a rare ear reconstruction patient seek-
ing reoperation, one can divide patients into the following three groups: (1) those
who underwent what can best be described as a rearrangement of the microtic
vestige in early childhood but little else until their presentation years later (see p.
790); (2) those who have been through “standard” staged reconstruction with a
costal cartilage framework who have lost part of the framework as a result of infec-
tion or partial ap compromise, without additional efforts to correct the deformed
auricle (see p. 791); and (3) those who have had failed initial reconstruction, at-
tempted fascial ap salvage, and subsequent further failure (see pp. 793 and 794).
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This 34-year-old patient who had a single unsatisfactory attempt at reconstruction
of his conchal remnant–type microtia in childhood underwent reconstruction fol-
lowing an approach similar to the standard reconstruction. Before and after rst-
stage reconstruction, he still had a relatively limited amount of lobular tissue. The
ear was elevated and the lobule augmented with a dermal fat graft. The result is
shown 2 years postoperatively after still further augmentation of the lobule and mi-
nor additional soft tissue revision.

This 12-year-old girl had undergone multiple unsuccessful reconstructive proce-
dures for lobular-type microtia. Despite multiple surgeries and scarring, the skin
was still thin and supple and could be used to cover a new cartilage framework.The
new framework was constructed and placed through an incision located along the
helical rim, which allows resection of the old framework and maintains the vascu-
lar supply to the ap.
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A close-up view after completion of the elevation of the ear and lateral views of the
completed reoperated repeat reconstruction at 2 years postoperatively are shown.

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Although it would seem intuitive that the patients in the rst group are good can-
didates for placement of a costal cartilage framework following much the same ap-
proach as a typical reconstruction of a lobular or conchal remnant–type microtia
(see p. 790), with minor variations, it may seem less obvious that some patients in
the second group may still be candidates for a new cartilage framework placed in
the same skin envelope.This is a group of patients in whom I may have in the past
resorted to a TPFF and skin graft for total replacement of the skin envelope, but fol-
lowing examples demonstrated by Firmin,20 I now recognize that this is not only
unnecessary but is often a more extensive procedure than necessary. Provided these
cases are well selected, the skin coverage will still be more delicate and of a better
color match than skin-grafted TPFF, and one also avoids the additional donor scar
in the scalp (see p. 791).
What distinguishes this latter group is the thin supple quality of the skin, which
moves freely over the surface of the amorphous framework below. In these patients,
one can meticulously elevate the skin off of the framework through an incision
along the helical rim (typically at the junction with the postauricular skin graft), re-
move the unacceptable framework and release tethering scars, and then place the
new framework (see p. 791). The postauricular graft can typically be raised with
some underlying fascia as a ap to add to the overall envelope and in some cases al-
low for some depth to the postauricular sulcus from the outset. There is a limit as
to how much conchal excavation can be accomplished initially, without compro-
mising the vascularity of the skin envelope.The primary goal of the rst reopera-
tive surgery is to place a well-sculpted framework beneath the thin, delicate, ex-
ible skin envelope, as well as correct any malposition of the earlier reconstruction.
Once the new framework is in place, subsequent procedures can excavate the con-
cha, construct the tragus, and further de ne the postauricular sulcus following tech-
niques used in typical successful staged reconstruction.
SKIN AND CARTILAGE DEFICIENCY
WITH MODERATE AND SEVERE SCARRING
The third group of patients typically presents with a history of multiple surgeries
fraught with episodes of infection, ap loss, cartilage exposure, and multiple re-
gional aps for attempted salvage. Often these aps, even if done successfully, may
have been delayed prior to attempted salvage for the cartilage vascularity to be
compromised.This subsequently results in partial or complete cartilage framework
absorption. If the previous failure and attempted salvage has not compromised the
super cial temporal artery, or at least left a clearly de ned length of postauricular
artery and occipital arteries, and there is still donor costal cartilage available, one can
consider discarding all or most of the previous ear vestige. An effort should be made
to keep usable parts of the vestige as one would in reconstructing a conchal rem-
nant microtia, and at the very least one should retain enough tissue to reconstruct
the lobule.

This 7-year-old child had undergone seven previous attempts at reconstruction to
correct lobular-type microtia, resulting in a small, amorphous ear. A new framework
is placed and covered with a TPFF and split-thickness skin graft, retaining enough
of the original tissue to create the tragal prominence and lobule. At 3 months post-
operatively of the rst stage of repeat reconstruction, the fascial ap is thinning and
the ear details are more evident.
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The result of the one-stage repeat reconstruction is shown in close-up view 6 years
after the reconstruction. Full lateral views show symmetry with the contralateral
normal ear.
The staging of the reconstruction is similar both in this setting and in reconstruc-
tion of traumatic loss of the auricle.Templates are made for the framework and for
placement of the ear. The cartilage is harvested and the framework constructed.
The framework is placed and covered with the fascial ap, and the ap is covered
with split-thickness skin graft with the scalp the preferable donor site for the graft.
Vacuum drains are placed beneath the framework and ap, and beneath the donor
scalp aps.The postoperative treatment is similar to the standard reconstruction, yet
the time between the rst (new reconstructive stage) and subsequent stages may be
longer than with skin ap coverage. Grafted fascial aps are quite variable in the
time course of thinning to show the details of the underlying cartilage. Regardless
of the progress, I will often wait at least 6 months between the rst and subsequent
stages. Patients must be aware that in some cases the thinning may take as much as
a year before the framework details are well de ned. One can expect continued
thinning and improvement in skin color and exibility of this ap over at least 2 to
3 years, if not longer. If one has properly prepared these patients for their repeat re-
construction, they generally are accepting of the slow healing process and they are
patient enough to look toward the nal result, even if it takes from months to years.

REOPERATION FOR SYMMETRICAL
EAR POSITIONING
795
Chapter 23
Staged Sequential Procedures for Ear Reconstruction
Oblique and lateral views show this patient’s ear to be low lying and with the up-
per pole incompletely reconstructed. Maintaining an inferior pedicle, the ear is el-
evated and transposed posterosuperiorly using a template from the normal ear for
positioning.With the ear repositioned, a superiorly based skin ap transposes from
posterior to the remnant to anterior to it to ll in the preauricular defect created
as the ear moves posteriorly.
In a lateral view 6 months after the repositioning, this ap can be seen anterior to
the ear and the superior pole defect is now more evident.

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Three views demonstrate the improved symmetry 6 months after the upper pole
reconstruction with local ap and conchal cartilage graft and shortly after minor ad-
ditional soft tissue reconstruction.
Although discussed earlier in the section on treatment of auricular dystopia, a nal
comment seems appropriate regarding the proper positioning of the reconstructed
ear. One of the areas of greatest concern to patients seeking further microtia recon-
struction is the malposition of the reconstructed ear.Typically the ear is positioned
anterior and inferior to its normal counterpart (as well as rotated from a “normal”
axis). Some patients may present with dystopia and an incomplete reconstruction
and will need both correction of dystopia and additional staging of surgeries. Each
case needs to be assessed for the extent of surrounding scar and the distance of
movement that is necessary for optimal symmetry.The rich vascular supply in this
area will allow a reasonable amount of elevation and movement of the recon-
structed ear, but a wide enough pedicle needs to be maintained (with at least as
much attachment as one sees at the second-stage ear elevation in routine microtia
reconstruction) to avoid vascular compromise. Once again, an x-ray lm template
is used to determine the extent and direction of movement needed to create ear
symmetry. One can also assess how much of the previous reconstructed, or par-
tially reconstructed, ear needs to be “added” to complete the reoperative recon-
struction. The movement will often require interposition of a skin or fasciocuta-
neous ap from behind the dystopic auricle to ll the defect anterior and medial to
the ear, as is needed in the early transposition of the vestige discussed above (see pp.
783 and 795).

Once the dystopic ear, or partially reconstructed ear, has been repositioned, addi-
tional reconstruction may require additional cartilage grafting from either the con-
tralateral concha (see p. 796) or chest to complete the helical rim reconstruction,
followed by nal adjustments of the soft tissues of the helical rim or lobule.
Each case must be carefully assessed, and certainly some patients must be coun-
seled that the risk of distortion or loss of the reconstructed ear does not warrant the
risk of this movement. They should also be aware of the additional scars that will
result from the transposition of skin anterior or inferior to the repositioned auricle
in cases where the anterior skin is not lax enough to allow advancement back to the
newly positioned ear. Some patients, although unhappy with the ear position, may
not be willing to accept these additional scars, and the surgeon should then coun-
sel acceptance of the current deformity.
ROLE OF PROSTHETIC RECONSTRUCTION
Not surprisingly, the success of reoperative ear surgery is highly dependent on care-
ful case selection. In most cases, outside of those with previous limited surgery and
limited scarring, one should consider and discuss the possibility of prosthetic recon-
struction. At the very least, any patient who presents with a history of multiple
previous ear reconstruction surgeries and dissatisfaction with the size, shape, posi-
tion, and lack of ne detail in their result should be evaluated for prosthetic recon-
struction.21,22 This includes patients who have had previous reoperative surgery
with cartilage previously harvested from both sides of the chest. These patients
should meet with the surgeon involved in osteointegration of the abutment for
the prosthetic ear (if it was not you) and meet with the anaplastologist who will be
creating the prosthesis.They should understand not only the obvious bene ts of the
excellent match in size, shape, and color of the current prostheses, but also the long-
term need to replace the prosthesis, maintenance of the abutment, and the costs of
prosthetic replacement. In my practice, even in cases where I am con dent of the
success of an autogenous reconstruction, I have the patient follow through with
this evaluation and discussion, thus ensuring an informed decision to proceed with
a new set of staged procedures. This routine also provides a means of informing
the patient of an additional “ nal option” if the reoperation is unsuccessful.
CONCLUSION
Successful staged reconstruction of the ear, whether for microtia or major acquired
ear deformities, requires meticulous attention to all aspects of the available auricu-
lar and donor tissue, and the soft tissue environment surrounding the planned re-
construction. Whether one chooses to follow a Nagata, Firmin, or Brent model
for the initial microtia reconstruction, careful attention to the vascular supply of
the skin aps will minimize the risk of ap ischemia and cartilage exposure. With
considerable variation in auricular remnants, meticulous planning is perhaps the
most important factor in reducing complications.
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The challenges faced in successful reconstruction of the “virgin microtia” or rst at-
tempt at reconstruction of an acquired ear deformity are signi cantly magni ed
when these procedures have already failed. Reoperation for a previously unsatisfac-
tory result must now take into account the fact that the recipient bed is now scarred
and the donor tissue more limited. Successful reoperation requires familiarity with
all of the available reconstructive options and the expertise of the operating sur-
geon. One must ensure that the patient understands the complexity and likely
staged nature of the reconstruction and be reasonably certain that the patient’s ex-
pectations and surgeon’s capabilities are in synch. Finally, the alternatives of accept-
ing the current result, at one end of the spectrum, and prosthetic reconstruction, at
the other end, must always be considered and discussed. With all these issues in
mind, the surgeon, with consummate skill and on occasion a little luck, will see
that the patient does not require additional reoperation.
References—With Key Annotated References
1. Brent B.The correction of microtia with autogenous cartilage grafts: I.The classic deformity.
Plast Reconstr Surg 66:1, 1980.
This classic paper on Brent’s modi cations of the early work of Tanzer is the cornerstone of the mi-
crotia reconstruction learned and taught by most surgeons who developed an interest and expertise in
reconstruction.
2. Brent B.The correction of microtia with autogenous cartilage grafts:II. Atypical and complex
deformities. Plast Reconstr Surg 66:13, 1980.
This is the second part of the classic paper on Brent’s modi cations of the early work of Tanzer, rep-
resenting the cornerstone of the microtia reconstruction learned and taught by most surgeons who de-
veloped interest and expertise in reconstruction.
3. Nagata S. A new method of total reconstruction of the auricle for microtia. Plast Reconstr
Surg 92:187, 1993.
With Nagata’s meticulous attention to detail quite evident, this article demonstrates the rst signi -
cant modi cation of the techniques described by Brent. First-stage lobule rotation, tragal construction
in the rst stage, and modi cation of the second stage are particularly important. Careful attention to
the design of the skin aps, use of a subcutaneous pedicle to augment vascularity of the ap, and lob-
ule rotation in the rst stage are perhaps the most signi cant parts of this paper.Variations in frame-
work design were also carefully noted.
4. Nagata S. Modi cation of the stages in total reconstruction of the auricle:Parts I, II, III, IV. Plast
Reconstr Surg 93:221, 1994.
Subsequent parts of Nagata’s series of articles. Again, this paper demonstrates the rst signi cant
modi cation of the techniques described by Brent. First-stage lobule rotation, tragal construction in the
rst stage, and modi cation of the second stage are particularly important. Careful attention to the de-
sign of the skin aps, use of a subcutaneous pedicle to augment vascularity of the ap, and lobule ro-
tation in the rst stage are perhaps the most signi cant parts of the paper.Variations in framework de-
sign were also carefully noted.
5. Firmin F. Ear reconstruction in cases of typical microtia. Personal experience based on 352
microtic ear corrections. Scand J Plast Reconstr Surg Hand Surg 32:35, 1998.
6. Firmin F. La reconstruction auriculaire en cas de microtie. Principes, methods et classi cation.
Ann Chir Plast Esthet 46:447, 2001.
Although not as readily available as the Nagata papers in that they have not been published in the
English literature, Firmin’s modi cations of the Nagata technique, in particular the handling of the
soft tissue envelope, are well worth investigating. Her results are unequaled.

7. Beahm EK,Walton RL, Park C. Auricular reconstruction for microtia:Part I. Anatomy, embry-
ology, and clinical evaluation. Plast Reconstr Surg 109:2473, 2002.
8. Fukuda O,Yamada A. Reconstruction of the microtic ear with autogenous cartilage. Clin Plast
Surg 5:351, 1978.
9. Bauer BS, Patel PK. Congenital deformities of the ear. In Bentz ML, ed. Pediatric Plastic
Surgery. Stamford, CT: Appleton & Lange, 1998, p 359.
10. Bauer BS, Patel PK. Integrating auricular reconstruction with distraction osteogenesis hemi-
facial microsomia. In Diner PA,Vazques MP, eds. International Congress on Cranial and Facial
Bone Distraction Processes. Bologna, Italy: Monduzzi Editore, 1997, p 87.
11. Brent B. Auricular repair with autogenous rib grafts: Two decades of experience with 600
cases. Plast Reconstr Surg 90:355, 1992.
12. Mladick RA. Salvage of the ear in acute trauma. Clin Plast Surg 5:427, 1978.
13. Brent B, Byrd HS. Secondary ear reconstruction with cartilage grafts covered by axial, ran-
dom and free aps of temporoparietal fascia. Plast Reconstr Surg 72:141, 1983.
This is one of the best papers outlining the anatomy and versatility of the temporoparietal fascial ap
in secondary ear reconstruction. It demonstrates the varied way the pedicle can be designed for both re-
gional and microvascular transfer.Although the authors describe a case in which the ap is used based
on a random blood supply, I would strongly caution others about the reliability of this randomly based
ap.
14. Brent B, Upton J, Acland RD, et al. Experience with the temporoparietal fascial free ap. Plast
Reconstr Surg 76:177, 1985.
15. Tegtmeier RE, Gooding RA.The use of a fascial ap in ear reconstruction. Plast Reconstr Surg
60:406, 1977.
16. Nagata S. Secondary reconstruction for unfavorable microtia results utilizing temporoparietal
and innominate fascia aps. Plast Reconstr Surg 94:254, 1994.
17. Park C, Shin KS, Kang HS, et al. A new arterial ap from the postauricular surface:Its anatomic
basis and clinical applications. Plast Reconstr Surg 82:498, 1998.
18. Hirase Y, Kojima T, Hirakawa M. Secondary ear reconstruction using deep temporal fascia af-
ter temporoparietal fascial reconstruction in microtia. Ann Plast Surg 25:53, 1990.
19. Brent B.The acquired auricular deformity:A systemic approach to its analysis and reconstruc-
tion. Plast Reconstr Surg 59:475, 1977.
Although I have described a different manner of classifying acquired deformities than the one de-
scribed in this paper by Brent, his classi cation by different anatomic regions of the ear with exam-
ples of each, and a well-researched bibliography make this a great review article and organized ap-
proach to resident learning.
20. Firmin F. Otopoïèse après amputations traumatiques:Amputations totales ou subtotales et par-
tiells. Encycl Med Chir (Editions Scienti ques et Médicales Elsevier SAS, Paris). Techniques
chirurgicales—chirurgie plastique et esthètique, 45-522, 2001, 20.
21. Wilkes GH, Wolfaardt JF. Osseointegrated alloplastic versus autogenous ear reconstruction:
Criteria for treatment selection. Plast Reconstr Surg 93:967, 1994.
22. Thorne CH, Brecht LE, Bradley JP, et al. Auricular reconstruction:Indications for autogenous
and prosthetic techniques. Plast Reconstr Surg 107:141, 2001.
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1. The decision to proceed with first-stage reconstruction of the microtic ear
should be based on each of the following except:
a. The growth characteristics of the opposite normal ear
b. The size of the chest and therefore available cartilage for the framework
construction
c. The parents’urging to start the reconstruction because of anxiety about
their child’s deformity
d. The psychosocial development of the patient
2. The typical rst-stage reconstruction of a lobular-type microtia following the
Nagata approach includes each of the following except:
a. Maintaining a subcutaneous pedicle to augment the vascular supply of
the superior ap
b. Construction of the external auditory canal with skin graft lining
c. Lobule rotation
d. Construction of a three-dimensional costal cartilage framework including
construction of the tragus
3. The best option(s) for reconstruction of a multiply operated failed microtia re-
construction with malpositioned scarred remnant, scalp scarring with dif culty
identifying the presence of the super cial temporal artery superior to the scar is:
a. Tissue expansion of the adjacent not scarred skin for coverage of a new
cartilage framework
b. Coverage of a new framework with a contralateral free temporoparietal
fascial ap and skin graft
c. Recommendation for placement of osseointegrated implants for xation
of a prosthetic ear
d. Deep temporal fascial ap coverage of a Medpor or silicone framework
4. The critical factor(s) to consider in assessing a patient for reoperative surgery of
the ear include:
a. The number of previous surgeries
b. The availability of donor cartilage
c. The remaining usable parts of the auricular vestige
d. The patients level of expectation
5. Reconstruction of the microtia patient with auricular dystopia differs from more
classic forms of microtia reconstruction in the following way(s):
a. Need to construct a costal cartilage framework
b. Need to reposition the vestige and future reconstruction in a more pos-
terior-superior position to gain optimal symmetry
c. Need to augment the costal cartilage framework to correct for underly-
ing skeletal hypoplasia
d. Need to await completion of all skeletal reconstruction before beginning
the reconstruction of the ear
R EVIEW QUESTIONS

801
Every year approximately 600,000 patients with skin cancer are treated in the
United States.This rough estimate does not re ect the actual incidence, which may
be far greater.The three principal histologic types of tumors are (1) basal cell car-
cinoma (BCC), (2) squamous cell carcinoma (SCC), and (3) melanoma. BCC ac-
counts for approximately 90% of cutaneous malignancies of the head and neck.
They are so common that physicians frequently do not consider them to be re-
portable forms of cancer. In addition, many of these tumors are easily and effectively
treated on an outpatient basis by excision, with the patient under local anesthesia.
For these reasons,exact statistics are dif cult to obtain.Melanoma has a different bio-
logic behavior.
Surgery for Recurrent Cutaneous
Malignancies of the Head and Neck
Grant W. Carlson
C ha pter 2 4
Reoperative Problems
Donor site
Poor color/texture match
Excessive ap bulk
Timing of reconstruction
Local recurrence
I have but one lamp by which my feet are guided,
and that is the lamp of experience.
I know no way of judging of the future but by the past.
Edward Gibbon
Head and Neck Reconstruction

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It is widely believed by researchers that exposure to ultraviolet radiation is the pri-
mary etiologic agent involved in the evolution of cutaneous malignancies. There-
fore, because the head and neck area is generally exposed to sunlight, 90% to 95%
of skin cancers arise in this area.The evolution of actinically damaged skin to malig-
nancy is a slow process, usually taking many years. Other factors implicated in the
development of cutaneous carcinoma include radiation dermatitis, chronic wounds
(Marjolin’s ulcer), immunosuppression, and exposure to certain chemical agents
such as arsenic. The predisposition to develop multiple basal cell carcinomas at an
early age is associated with xeroderma pigmentosa and the nevoid basal cell carci-
noma syndrome.
Mortality associated with nonmelanoma skin cancer is infrequent, accounting for
1500 deaths per year in the United States. There are 50,000 cases of invasive
melanoma diagnosed in the United States each year, which account for 8000 deaths.
The risk of local and regional recurrences can often be correlated with histopatho-
logic prognostic factors.1
The history of a previous recurrence or evidence of inadequate primary
tumor excision (positive margins) portends the highest risk for local
recurrence for all types of skin cancer.
Traditional margins of excision of the primary tumor may have been narrowed at
the primary surgery because of cosmetic considerations, especially in the middle
third of the face.
Although regional and distant metastases can occur with nonmelanoma skin can-
cer, they typically develop in only 5% to 7% of cases, and generally arise in associ-
ation with SCC. A much more common problem is local recurrence of the tu-
mor, which can result in tissue destruction and invasion of adjacent structures. In
addition, when there are problems with recurrent tumors, the risk of regional and
distant metastatic disease increases.
Histology
Location
Positive margins
Previous treatment
Size
Immunosuppression
Risk Factors for Local Recurrence
Factors associated with an increased incidence of recurrence include an aggressive
histologic condition (SCC and the morphea type of BCC), increased size of the
primary lesion (greater than 2 cm in diameter), and location of the primary lesion
in the midface around the nose, periorbital areas, and preauricular and postauricu-
lar regions.

FIGURE H ZONE OF THE FACE
Swanson2 described these areas of high risk as the H zone of the face;the increased
risk of recurrence in these zones is probably associated with embryologic planes of
fusion. In addition, lesions arising in previously irradiated skin and in immuno-
compromised patients tend to act more aggressively and are more likely to recur.
SCC has a higher risk for local recurrence when the tumor is undifferentiated or
multicentric at initial diagnosis, and when perineural invasion is present. In older in-
dividuals, sun-damaged skin commonly has foci of carcinoma in situ near invasive
carcinoma.
The growth pattern of BCC has been correlated with the risk of local recurrence.
Although nodular lesions have a low local recurrence risk, morpheic, super cial
multicentric, and micronodular forms have a high risk of recurrence and are prone
to recur even after apparent complete excision. Histologically, BCC may exhibit
features of squamous metaplasia and have the clinical characteristics of both types
of skin cancer.
The development of local recurrence after resection of primary melanoma is not a
common event. Factors associated with local recurrence are tumor thickness, ulcera-
tion of the primary lesion,histologic type,and age.Local recurrence of primary mela-
noma is directly related to tumor thickness. The average thickness of melanomas
diagnosed today is now approximately 1 mm; therefore local recurrence will be
3% or less. Lentigo maligna and desmoplastic melanoma are two histologic sub-
types that are prone to local recurrence.
GENERAL CONSIDERATIONS
The soft tissue and bony supporting structures in the head and neck are very im-
portant functionally and aesthetically. Recurrent malignancies can have a devastat-
ing impact on a patient’s ability to maintain normal function and appearance. Prob-
lems with speech, deglutition, respiration, and the special sensory organs may
develop as the result of advanced or neglected lesions. Therefore the trend is to
treat these lesions in an aggressive manner with appropriate ablative and recon-
structive surgery to preserve adequate function and cosmesis. Rarely is surgery con-
traindicated in these patients except in cases of extreme debilitation or poor per-
formance status. With modern skull base techniques, even lesions that invade
intracranially can be approached in a sound oncologic fashion. However, based on
anatomic considerations, surgery may be withheld for advanced lesions that involve
the cavernous sinus, optic chiasm, or intracranial portion of the carotid artery. In-
volvement of these structures may be considered indicative of unresectability.With
each recurrence, there is a decreasing chance for cure.
The patient who is to undergo a reoperative procedure may present with a broad
spectrum of problems with recurrent cancer.The rst recurrence may be found in
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a noncritical area, such as the forehead, cheek, or neck, or a patient with a long
history of multiple recurrences managed with surgery and radiotherapy may pre-
sent with an advanced lesion that involves vital structures in the head and neck.
Every patient is obviously concerned about impaired function and
cosmesis. A well-coordinated team approach to management is critical
in allaying the patient’s fears and anxieties and achieving an optimal
result.
The patient should be assured that a multidisciplinary approach to both tumor con-
trol and reconstruction provides the best hope for not only curing the cancer but
also returning the patient to a socially acceptable level of function and appearance.
The team comprises a head and neck surgeon, possibly a neurosurgeon, a plastic and
reconstructive surgeon, a radiation oncologist, a medical oncologist, a physical ther-
apist, a speech therapist, nursing staff, and a medical social worker.
Large, recurrent tumors may directly invade or closely approach one or
several important functional or aesthetic structures, and resection is
required for proper oncologic control of the tumor.
The surgeon should make the patient aware that it may be necessary to sacri ce
structures such as the nose, eye, ear, facial nerve, or a considerable amount of bone
and soft tissue in the area. In some cases nonoperative therapies may be more de-
sirable. For example, BCC that recurs at the medial canthus of the eye is well treated
with radiation therapy and shielding of the globe. In cases in which extensive re-
sections are anticipated, preoperative mapping of planned margins can be per-
formed using multiple punch biopsies of surrounding normal-appearing skin. Ad-
equate preoperative planning and patient counseling are absolutely essential to avoid
unpleasant surprises postoperatively.
These principles do not apply in the case of melanoma because of the frequency of
satellite lesions that have no continuity with the index recurrence. It is not un-
common to see separate pigmented nodules in the underlying fascia as a dermal le-
sion is being excised. CT scans with short interval images may show these clinically
occult satellites. For this reason, wide local excision as performed for the primary
lesion is not of bene t in the treatment of recurrent melanoma. Unfortunately, no
studies have evaluated the optimal width of resection for recurrent melanoma.
TIMING
Major ablative surgery can lead to the loss of special sensory functions such as hear-
ing, sight, smell, and taste, as well as the ability to eat, swallow, and speak normally.
The aesthetic impact of these procedures may be socially debilitating. Therefore
proper consideration for the functional and cosmetic aspects of the reconstructive
phase of treatment is critical if patients are to maintain a meaningful quality of life.

As in all cases in which a patient is faced with the treatment of a malignant lesion,
particularly one that is recurrent, the patient generally likes to proceed with treat-
ment as expeditiously as possible. However, this sense of urgency should in no way
impair the process of proper multidisciplinary planning for the approach to the
problem. All consultants should see the patient in the clinical setting preoperatively
to discuss their respective roles in the treatment plan.Time should also be allowed
for a group consultation if needed.
Although the procedures may be quite long and involved, every attempt should be
made to perform both the ablative and reconstructive portions of the procedure at
the same operation.
The critical issue in the management of patients with recurrent cutaneous malignan-
cies is proper clearance of all gross and microscopic disease. This may be achieved
adequately with surgery alone or may require additional adjunctive therapy such
as postoperative radiation therapy. Systemic chemotherapy can result in substantial
responses, but such improvements are frequently incomplete and short lived. The
reconstructive phase of therapy should be appropriately delayed until all oncologic
concerns have been addressed.
Determining the adequacy of tumor clearance at the time of surgery
relies on histopathologic evaluation of the surgical margins using im-
mediate frozen sections and paraf n-embedded permanent sections.
In general, frozen section control of margins can be relied on when
the excised specimen is small and involves only skin and the super -
cial layers of the underlying subcutaneous tissue.
However, when the amount of tissue excised is large or involves multiple tissue
types such as skin, fat, muscle, bone, and cartilage, it is best to await more accurate
permanent sections before undertaking reconstructive surgery.The patient may re-
quire several surgeries before it can be determined that the margins are adequately
clear of the neoplasm, based on these permanent sections. Between these phases of
the operation the wounds can be treated with appropriate dressings. In the situation
in which surgical margins cannot be adequately evaluated with frozen sections, the
reconstructive phase of the operation must be delayed until the nal margins of
the resection are evaluated on permanent sections. However, when resection results
in the exposure of vital structures such as the brain and major vascular structures,
reconstruction cannot be delayed.
The nal alternative approach to treatment is to delay reconstruction
for a prolonged period, or to perform no reconstruction and allow the
wound to heal secondarily.This approach is taken in certain high-risk
situations in which covering the site with a thick ap may be unwise
from an oncologic standpoint because it would prevent continued tu-
mor surveillance.
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Simply allowing the defect to heal by secondary intention or covering it with a
thin, split-thickness skin graft may allow improved ability to observe a particular
area such as the nasal lining. If additional reconstruction is needed or desired, sur-
gery can be undertaken 18 to 24 months later, when the surgeon is con dent that
the patient is tumor-free.
Margins clear but
“aggressive” histopathologic
condition detected
Postoperative radiation
Late reconstruction,
8 weeks to 11 2 years,
depending on situation
Margins clear
Early reconstruction
in motivated patients
Involves skin or
subcutaneous tissue only
Resection with
frozen section analysis
of margins
Involves critical structures
Resection
Permanent histopathologic evaluation
of margins is performed
WHEN TO RECONSTRUCT
Recurrent s kin cancer requiring total/partial rhinectomy
Permanent histopathologic evaluation
Margins
clear
Reconstruct
at 1 to 5 days
Consider adjunctive
therapy if
“aggressive” lesion
Margins
positive
Margins positive
Reresect
positive margins
Permanent
histopathologic
evaluation of margins
is performed
Margins clear
but “aggressive”
histopathologic
condition detected
Reconstruct
Consider adjunctive
therapy
Margins clear
Immediate reconstruction
Margins clear
Reconstruct
Recurrent cutaneous malignancy
(BCC and SCC)

PATIENT EVALUATION: BCC AND SCC
Two thirds of patients with locally recurrent nonmelanoma skin cancer are seen
within 3 years of initial treatment. Overall, over 90% of recurrences will appear
within 5 years. The clinical appearance of recurrent skin cancer depends on both
the type of recurrence and the prior treatment. Marginal recurrences usually de-
velop in or around the scar. Distortion produced by treatment can make detection
of recurrences dif cult. Scarring can result in nodule formation that resembles tu-
mor recurrence. Recurrence under a skin graft usually results in nodule formation.
Deep recurrence under a ap is more dif cult to recognize because of the thick-
ness of the tissue. Radiographic studies are helpful to assess local tumor extent.The
most common studies are CT and MRI. These studies are generally used when
there is a question of involvement of the orbit, paranasal sinuses, mandible, base of
the skull, and intracranial contents. These studies also allow assessment of the re-
gional cervical nodes if there is a question of metastatic involvement. Panoramic
dental radiographic lms are helpful in evaluating mandibular invasion. A workup
for distant metastases includes a radiograph of the chest and a set of liver function
studies.
Based on the extent of the local and regional disease, the proper resection can be
planned. At this point it may be necessary to solicit the help of a colleague with ex-
pertise in neurosurgery as part of a craniofacial approach. The need for a regional
lymphadenectomy (parotid or cervical) is determined by the presence of palpable
disease or radiographic evidence of involvement.The amount of bone and soft tis-
sue loss can be anticipated, and the desired reconstructive plan can be made.
When the surgeon discusses the planned resection and reconstruction with the pa-
tient, it is essential to prioritize the goals of the surgery. The most important goal
should be total removal of the tumor, thereby ridding the patient of a potentially
lethal disease.The remaining goals involve the reconstructive phase of the operation
and include creating a setting for primary wound healing, restoring normal func-
tion, and preserving acceptable cosmesis. The patient should be made aware that
achieving the last three goals may not be entirely possible with the rst operation,
and that several revisions may be necessary before the nal result is realized.
MELANOMA
Local recurrent melanoma has a high incidence of simultaneous regional or distant
disease; therefore a careful evaluation is required.3 The history should focus on
symptoms of CNS, pulmonary, gastrointestinal, and musculoskeletal metastases.The
physical examination should document the extent of the local recurrence or recur-
rences, and signs of regional and CNS metastases.Visceral metastases are best found
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on CT or MRI scans, but whole-body PET scanning is increasingly used to eval-
uate systemic metastases. Most patients who are asymptomatic will have normal
screening tests.
TREATMENT MODALITIES FOR BCC AND SCC
Primary cutaneous malignancies can be treated using a number of therapeutic
modalities including curettage and desiccation, cryosurgery, laser excision, and sur-
gical excision. For selected lesions Swanson2 reported cure rates of 92% to 97%
with all of these modalities. However, it is less desirable to use these conservative
methods for the patient who has a recurrent tumor. Recurrent tumors may lend
themselves to simple reexcision or may require extensive radical surgery and ma-
jor reconstructive efforts involving multiple surgical specialties. Alternatively, radi-
ation therapy may play a role in the management of these dif cult problems.These
lesions are best handled with surgical excision until margins are deemed clear. In
high-risk areas, resection with frozen section (Mohs technique) is used.
MOHS FRESH TISSUE CHEMOSURGERY TECHNIQUE
In high-risk areas, resection with frozen section (Mohs technique) is used. This
chemosurgery centers on the ability of the surgeon to excise, immediately x, and
analyze the margins to determine the adequacy of resection.This technique allows
the surgeon to precisely and topographically delineate the extent of the tumor, and
accurately control the margins of excision, thus removing the tumor with maximal
preservation of surrounding normal tissue.When properly applied, the Mohs tech-
nique can achieve a high cure rate. The technique is particularly suited for recur-
rent and high-risk lesions involving primarily skin and underlying soft tissue. The
technique is limited when tumor involves cartilage and bone.With diffuse growth
patterns the nal excision may extend well beyond the visible tumor. Excision can
become a lengthy procedure requiring general anesthesia and multiple frozen sec-
tion margins. The patient should be informed preoperatively about the possible
extent of resection to minimize the shock of dis guring resections.
R ADIATION THERAPY
Radiation therapy was formerly widely used in the treatment of primary and recur-
rent skin cancer. Radiation therapy has the ability to control the majority of skin
cancers, but it generally results in overtreatment in most situations. Surgical excision

is certainly more expeditious and allows analysis of the margins of resection. Radi-
ation therapy is not as effective when tumor invades underlying structures such as
bone and cartilage, and this treatment carries with it the risk of delayed carcinogen-
esis and radiodermatitis. Radiation is primarily used when there is a large eld to be
treated, when the patient is a poor operative risk, when required in a palliative set-
ting, and when called for as an adjunct to surgery in cases in which there is tumor
remaining at the margins of resection. Adjuvant radiation therapy is commonly ad-
ministered after surgery when perineural invasion is exhibited by the cancer, and in
cases of desmoplastic melanoma. Recurrence after radiation therapy is an ominous
prognostic sign.
MELANOMA
Local recurrence of malignant melanoma is related to initial tumor thickness.Thin
melanomas with a tumor thickness of 1 mm have a very low recurrence rate.4
Thicker melanomas and lentigo maligna and desmoplastic subtypes have a higher
recurrence rate. Lentigo maligna melanoma occurs primarily in the head and neck
area. It is characterized by a prolonged radial growth phase. Desmoplastic melanoma
is dif cult to diagnose clinically and has a high incidence of local and systemic re-
currence.
Although local recurrence of melanoma is clearly associated with a poor prognosis,
it is not uniformly fatal. About 20% of patients with melanoma remain free of re-
currence 3 years after treatment.Therefore it is important to remove even multiple
sites of disease in the same region.
Resection of recurrent melanoma should be performed by removing the lesion and
a margin of surrounding skin. Centimeters of normal tissue margin are unnecessary.
As stated previously, there have not been any studies to compare extensive versus
limited local excisions for recurrences, as there have been for primary tumors. Ad-
jacent fascia, muscle, nerve, or bone should be included in the excision to achieve
a clear margin if the recurrence is limited to a single site. Black silk or nylon sutures
should not be used because they may mimic a recurrence when used for subcuta-
neous sutures or under skin grafts after excision of melanomas. Multiple-site recur-
rences have such a poor prognosis that debilitating resections are not recommended.
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Surgery for Recurrent Cutaneous Malignancies of the Head and Neck

810
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
RECONSTRUCTION AFTER RESECTION
OF RECURRENT CUTANEOUS MALIGNANCIES
Recurrent cutaneous malignancies represent a more challenging reconstructive
problem when they occur in the head and neck. Elsewhere in the body, small re-
current skin cancers often can be treated by excision and primary closure. Other-
wise a skin graft or a local ap can almost always be used to reconstruct the large
defect. However, in the head and neck area both form and function play a large
role.The rst priority facing the reconstructive surgeon is to clear the area of resid-
ual or recurrent cancer.
GRAFTS VERSUS FLAPS
In general, with recurrent cutaneous malignancies in the head and neck, the sur-
geon must close a larger or more complex defect than defects that occur with pri-
mary skin cancers.The extent of resection and subsequent cure should not be com-
promised merely to “get by” with a smaller ap than the surgeon is comfortable
using. It is far more important to clear the area of cancer and plan the reconstruc-
tion using aps of adequate size, or possibly skin grafts.
Skin grafts are especially useful for recurrent skin cancers of the scalp
in which the periosteum can be preserved. Grafts, however, are usually
not as satisfactory on the face because of poor color and texture
match. In addition, contour problems can result in deformities that are
dif cult to reconstruct secondarily.
Skin grafts give the best results when used to replace entire aesthetic units in a
manner similar to facial burn reconstruction. Small grafts, however, will virtually al-
ways cause a patchwork effect and are satisfactory only as temporary coverage.
Flaps, particularly distant aps or free aps, are also plagued by color and texture
mismatch. However, ap revisions, as outlined in Chapter 25, are usually easier be-
cause of the abundance of high-quality elastic skin. Local aps are best reserved for
the secondary revision of distant aps and grafts unless they can be used to totally
close a defect and complete the reconstruction in one stage.

811
Chapter 24
Surgery for Recurrent Cutaneous Malignancies of the Head and Neck
A 65-year-old woman with a history of chronic lymphocytic leukemia presented
with recurrent BCC of the frontal scalp. Physical examination showed mobility of
the involved scalp. The area was widely resected down to the periosteum. A split-
thickness skin graft was used to close the defect.
This 34-year-old woman is shown after rectus abdominis musculocutaneous free
ap reconstruction, temporal bone resection, parotidectomy, and resection of the
mandibular ramus.The ap is bulky and has a signi cant color mismatch.
Patient Examples

812
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
CHEEK DEFECTS
Small secondary defects of the cheek can usually be closed with local aps. Either
a Mustarde cheek rotation ap or a posteriorly based cervicofacial advancement
ap can provide a satisfactory color and texture match when resurfacing the cheek.
Patient Example
This 52-year-old man illustrates the dif culty in treating lentigo maligna of the
face.The patient had a previous wide local excision and primary closure of the left
cheek. He now presented with a local recurrence.
Mohs micrographic surgery with permanent section histology was performed to
ensure adequate surgical margins before reconstruction.The surgical defect is much
larger than what was apparent clinically.

A cervicofacial advancement ap was used to close the defect. The ap was ex-
tended above the lateral canthus to prevent an ectropion.The dog-ear was removed
along the nasolabial fold forming a smooth cheek contour.
813
Chapter 24
Surgery for Recurrent Cutaneous Malignancies of the Head and Neck
The nal result shows good cheek contour and minimal tension on the lower lid.

814
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
DEFECTS INVOLVING THE SCALP
Recurrent skin cancer of the scalp is often problematic. Careful examination is nec-
essary to determine whether the cranial bones are involved. Physical examination
is most helpful in these cases. If the lesion is movable over the periosteum, the bone
is usually not involved. Radiologic examination is helpful in cases of suspected bone
invasion. Neurosurgery consultation should be obtained in all cases in which cra-
nial bone resection may be involved.
Patient Examples
This 71-year-old man presented with recurrent BCC under a previously placed
skin graft.The tumor was invading the cranial bone.

Postoperative appearance of the reconstruction is shown after ap atrophy.
815
Chapter 24
Surgery for Recurrent Cutaneous Malignancies of the Head and Neck
An intraoperative view after surgical resection of the temporal bone and acrylic
resin cranioplasty is shown. A saphenous vein graft was used to fashion an arteriove-
nous loop anastomosis between the facial vessels. A latissimus dorsi muscle was har-
vested and the loop divided to provide donor vessels. A split-thickness skin graft was
used to cover the free muscle ap.

816
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
This 82-year-old man presented with recurrent
SCC of the frontal scalp. The bone was eroded
and evaluation revealed no evidence of regional
or systemic metastases.The patient had multiple
medical problems and had been diagnosed with
senile dementia.
A full-thickness resection of the frontal scalp was performed. The exposed dura is
shown. A large scalp rotation ap was developed based on the super cial temporal
and occipital vessels.The donor site was close with a split-thickness skin graft.

DEFECTS INVOLVING THE ORBIT
If a recurrent tumor involves the orbital contents, orbital exenteration may be re-
quired. If the eyelids must be taken with the specimen, we nd that obturation
with a ap is the most effective way to achieve a healed wound. Total reconstruc-
tion of the upper and lower lids is not possible at the present time. If the lids can be
saved, the surgeon could consider ultimately trying to rebuild a socket that would
support a prosthetic globe. If only resurfacing of the orbit is required, transferring
the temporalis muscle and a skin graft is our preferred technique. Sometimes a skin
graft alone is satisfactory.
Resection of recurrent tumors involving the orbital contents usually
results in large complex wounds that require resurfacing of portions of
the cheek, lateral nasal wall, maxilla, palate, and orbit. We have been
most successful in closing these types of deformities with free aps
initially, followed by revision surgery to improve cosmesis or function
if the patient survives. The rectus abdominis flap, scapular flap, and
latissimus dorsi musculocutaneous ap all provide enough bulk to ll
a deep contour defect as well as enough skin to obturate or resurface
the cheek, orbit, lateral nasal wall, and palate if necessary.
Patient Example
817
Chapter 24
Surgery for Recurrent Cutaneous Malignancies of the Head and Neck
This 54-year-old man presented with recurrent SCC of the medial canthus. The
CT scan showed destruction of the medial orbit.

818
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
The resection required removal of the entire periorbita, including the lower lid,
orbital oor, and medial maxilla. Reconstruction was performed with a rectus ab-
dominis muscle free ap. The super cial temporal vessels were used as donor ves-
sels.The defect was covered with a split-thickness skin graft.
With time, atrophy of the ap occurred so that generally the contour and color
match were satisfactory.The patient desired no further revisions and has remained
free of recurrent disease.

DEFECTS INVOLVING THE NOSE
Small defects of the nose can be closed with local aps, skin grafts, or allowed to
close by secondary intention. Local aps give the best cosmetic results following the
reconstructive dictum of “replacement with like tissue.” Recurrent cancer involv-
ing the supporting cartilaginous structures requires more complex reconstructive
strategies. Good judgment is required to determine the timing of reconstruction.
Aggressive tumor biology, recurrence after radiation therapy, and an immunocom-
promised patient are all factors favoring delayed reconstruction.
The forehead ap can provide ample soft tissue coverage for total nasal reconstruc-
tion. Replacement of entire aesthetic subunits provides the best results. The carti-
laginous framework can be re-created with septal or conchal grafts and cranial bone
grafts, depending on the extent of resection. Lining can be fashioned from the re-
maining nasal mucosa or facial skin.
Patient Example
819
Chapter 24
Surgery for Recurrent Cutaneous Malignancies of the Head and Neck
This 64-year-old woman was referred for nasal reconstruction. She had a long his-
tory of BCC of the nasal tip. After undergoing multiple operations in the past and
receiving radiation therapy, she complained of increasing pain in the area. Exami-
nation revealed induration and rolled edges of the nasal margins. Biopsies revealed
basosquamous carcinoma with perineural invasion.

820
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
The patient underwent a completion rhinectomy and resection of the midface skin.
Delayed reconstruction was planned pending results of permanent histologic sec-
tions. Multiple margins were positive and resections were performed. The facial
skin was closed with advancement aps and the rhinectomy defect was left open.
The upper lip became tethered by scarring at the pyriform aperture. A delayed,
superiorly based nasolabial ap released the upper lip.

Reconstruction of the nasal deformity was deferred to allow tumor surveillance. A
nasal prosthesis was fashioned. Other principles regarding revision surgery after free
ap transfer to the head and neck are outlined in Chapter 25.
POSTOPERATIVE CARE
When debilitated patients undergo major procedures, special considerations come
into play during the postoperative period. Factors such as blood loss, prolonged
anesthesia, hypothermia, and major wounds can combine to place these patients at
substantial risk of early postoperative complications. For this reason we often place
these patients in the surgical intensive care unit for at least 1 or 2 days postopera-
tively. Slow weaning from the ventilator, aggressive pulmonary toilet, and careful
postoperative monitoring of vital signs and ap viability are best carried out in this
environment.
Alimentation, usually orally or via a feeding tube, is reinitiated on the rst postop-
erative day. Perioperative antibiotic therapy is continued for 2 days postoperatively
to reduce the sequelae of wound contamination and infection. Cardiovascular and
pulmonary complications occur frequently in elderly, debilitated patients;thus early
mobilization and careful monitoring of vital signs are essential early in the postop-
erative course.
The families of the patients who have undergone major ablative surgery and recon-
struction are often overlooked during this time. Considerable time should be spent
preparing families for the major alterations in the physical appearance and the func-
tional disability that these individuals will experience, particularly in the postoper-
ative course. Families can often greatly facilitate postoperative care if they are prop-
erly educated and involved.This involvement will increase the family’s con dence
when the patient makes the transition to the home environment.
821
Chapter 24
Surgery for Recurrent Cutaneous Malignancies of the Head and Neck

822
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
This 54-year-old man presented with recurrent SCC of the right temple. He had
a history of acquired immunode ciency syndrome. He had undergone resection
and scalp ap reconstruction followed by radiation therapy 6 months before pre-
sentation. Physical examination revealed chemosis of the right eye and right facial
nerve paralysis.The CT scan showed invasion of the temporal bone and orbit.
Patient Examples

A multidisciplinary team consisting of a head and neck surgeon, a neurosurgeon,
and a plastic surgeon performed the operation. A craniofacial resection was per-
formed, with resection of the temporal bone, parotid gland, mandibular ramus, and
orbital contents. A free latissimus dorsi ap was anastomosed to the cervical vessels
and covered with a skin graft.
823
Chapter 24
Surgery for Recurrent Cutaneous Malignancies of the Head and Neck

824
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
The wounds healed uneventfully but a large donor site seroma formed requiring
drain reinsertion.The back deformity resolved after prolonged drainage.The latis-
simus dorsi free ap atrophied rapidly resulting in a marked contour deformity.
Compare this result with the rectus abdominis musculocutaneous free ap recon-
struction depicted on p. 811. Although the musculocutaneous ap can be bulky, as
the muscle atrophies, the ultimate result after revision can be satisfactory.