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Reconstruction of Middle-Third Helical Traumatic Defects With a Two-Stage Approach: Retroauricular Flap and Costal Graft

Salmerón-González, Enrique MD, PhD; García-Vilariño, Elena MD; Pérez-García, Alberto MD; Ruiz-Cases, Alberto MD; Sanchez-Garcia, Alberto MD

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doi: 10.1097/PSN.0000000000000298
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The shape of the auricle, the convexities and concavities of its surface, and its thin coverage and weak vascularization present a surgical challenge in reconstructing partial auricular defects (Armin, Ruder, & Azizadeh, 2011). Several different techniques for auricular reconstruction have been described in the literature. The decision as to which technique is used depends on the injured soft tissue components and the size and location of the defect (Brent, 1990). Notwithstanding, when faced with auricular defects one-third to one-half the size of the auricle, it is common for plastic surgeons to hesitate in choosing between an aggressive technique for reconstruction, such as the use of costal grafts, or a less aggressive approach, such as the use of chondrocutaneous local flaps (Antia & Buch, 1967) or contralateral concha grafts (Brent, 1990).

In this report, we describe the case of a patient suffering from middle-third auricular avulsion following a bicycle accident. We treated the injury using a two-stage approach that included constructing a postauricular flap to cover the exposed cartilage immediately after the accident, and reconstruction of the cartilage framework using costal grafts 30 days later.


A 39-year-old man presented to our plastic surgery emergency department 2 hr after suffering a bicycle accident that resulted in avulsion of the cartilage and skin of the helix and antihelix in the middle-third of the ear (Figure 1). At the time of his initial evaluation in the emergency department, we noted no relevant alterations in the results of his laboratory blood tests. The patient history included only an appendectomy performed 12 years previously.

Auricle defect at initial evaluation. This figure is available in color online (

After abundant cleaning and irrigation of the wound with sterile 0.9% normal saline, we performed thorough debridement of the devitalized skin. After irrigation and debridement, we created a postauricular flap to cover the exposed cartilage using 6-0 nylon mattress and simple stitches (Figure 2). Although the postauricular flap left the ear attached to the mastoid skin, to prevent the risk of chondritis, immediate coverage of the cartilage was mandatory (Brent, 1990). Ciprofloxacin 500 mg every 12 hr was administered to the patient for 10 days and analgesics were ordered for pain relief. We performed a daily regimen of wound cleaning with chlorhexidine and the application of petrolatum gauze on the flap.

Auricle after closure with postauricular flap. This figure is available in color online (

Twelve days after the accident, the sutures were removed (Figure 3). Thirty days after the accident, we performed the second stage of the reconstruction by dividing the pedicle of the postauricular flap, covering the donor defect with a split-thickness skin graft, and utilizing carved costal cartilage to recreate the cartilaginous framework of the helix (Figure 4). The cartilage graft was fixed to the helix cartilage with 6-0 nylon suture, and the wounds were closed with 5-0 nylon using simple stitches. Three months after the second surgery, the patient had a good aesthetic result, was satisfied with the results, and had normal ear-to-mastoid distance with good quality scars (Figures 5 and 6). Postoperatively, the patient was instructed to apply moisturizing cream daily and use sunscreen with a sun protection factor of 50.

Surgical wound 21 days after the accident. This figure is available in color online (
Auricle after delayed reconstruction with costal graft, 1 day after the operation. This figure is available in color online (
Side view of the patient 3 months after reconstructive surgery. This figure is available in color online (
Front view of the patient 3 months after the reconstructive surgery. This figure is available in color online (


During the first few days following surgery, the patient requires analgesics for pain control. Assessing the wound and monitoring the amount of wound drainage is critical for preventing complications. To prevent pressure injury and flap damage, during the first 7 days following surgery, the patient should not lay directly on the ear.


The literature provides consistent recommendations regarding the management of certain types of auricular defects. Defects of less than 1.5 cm of the helix and antihelix can be repaired by wedge-shaped full-thickness excision and direct closure. This method leads to a reduction in the size of the ear and modification of its shape (Armin et al., 2011). Other techniques, such as local skin flaps, local chondrocutaneous flaps, composite grafts from the opposite auricle, and concha cartilage grafts covered by skin flaps, can also be used successfully for small defects (Brent, 1990). Repair of large defects generally requires the use of two-stage procedures with costal cartilage grafting and local flaps, such as temporal fascia flaps and skin grafts for coverage (Habiba, Khanm, Khurram, & Khan, 2018). However, when facing medium-sized auricular defects, one-third to one-half the size of the auricle, it is difficult to decide whether to perform a more aggressive procedure, such as obtaining costal grafts (Brent, 1990), or a less aggressive procedure using concha grafts or local chondrocutaneous flaps (Kovacic´, 2007).

The use of costal grafts allows the surgeon to carve the graft into the precise shape required for reconstruction of the defect, and also provides a strong scaffold. Concha grafts provide a smaller amount of cartilage that is weaker and may be insufficient to recreate the optimal shape desired for reconstruction (Brent, 1990). Also, obtaining cartilage through chondrocutaneous flaps may have limitations when attempting to achieve optimal positioning of the cartilaginous structure compared with using grafts because grafts do not depend on a pedicle and in-setting the graft is easier to perform (Brent, 1990). The most common side effect related to obtaining costal grafts is pain. Pneumothorax is a very rare complication that can be easily diagnosed and treated intraoperatively (Obert, Lepage, Ferrier, & Tropet, 2013).

One additional point is that contrary to the thick, hair-bearing postauricular skin of the superior third of the ear, the retroauricular skin of the middle-third of the ear is non-hair-bearing and thin. In contrast to superior-third defects, which require temporoparietal fascial coverage of autologous cartilage grafts for large defects, large middle-third defects can be closed with postauricular advancement flaps to cover the autologous cartilage (Armin et al., 2011).


Each auricular defect must be evaluated individually to identify the cause and the ability to combine local treatment (i.e., irrigation, debridement, and cartilage coverage) with prophylactic antibiotics. Early coverage of exposed cartilage is mandatory, whereas reconstruction can be delayed. In certain cases of medium-sized defects, a more aggressive procedure, such as reconstruction with costal grafts, can be justified to achieve the optimal shape and consistency of the cartilage framework of the auricle.


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Armin B. B., Ruder R. O., Azizadeh B. (2011). Partial auricular reconstruction. Seminars in Plastic Surgery, 25(4), 249–256.
Brent B. (1990). Reconstruction of the auricle. In McCarthy J. G. (Ed.), Plastic surgery (Vol. 3, pp. 2094–2152). Philadelphia, PA: Saunders.
Habiba N. U., Khan A. H., Khurram M. F., Khan M. K. (2018). Treatment options for partial auricle reconstruction: A prospective study of outcomes and patient satisfaction. Journal of Wound Care, 27(9), 564–572.
Kovacic´ M. (2007). Reconstruction of the middle third marginal auricular defect. Lijecnicki Vjesnik, 129(6/7), 201–204.
Obert L., Lepage D., Ferrier M., Tropet Y. (2013). Rib cartilage graft for posttraumatic or degenerative arthritis at wrist level: 10-year results. Journal of Wrist Surgery, 2(3), 234–238.
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