Introduction
The most prevalent tumours of the pinna include basal cell carcinoma (90 per cent of the malignant skin lesions of the head and neck), squamous carcinoma, and other tumours such as melanomas. These primarily affect white males over the age of 65 with a personal history of photoexposureReference Papa, Stocco and Arnež1 and have a slow evolution with infrequent metastasis.Reference Dubernard, Kleiber, Brenet, Louges, Veleine and Labrousse2 The treatment for malignant lesions of the pinna is radical surgery, leaving tumour-free margins.Reference Iljin, Antoszewski, Durko, Zieliński, Stabryła and Pietruszewska3–Reference Prasad and Janecka6 Radiotherapy may be useful as an adjuvant systemic treatment or in cases where there are affected edges.Reference Bacciu, Clemente, Piccirillo, Ferrari and Sanna7
Resection and reconstruction of lesions of the auricular concha are complicated because the skin in this area is thin and easily adheres to the auricular cartilage, it is difficult to find a donor site with a versatile pedicle, and aesthetic reconstructions require sufficient support to allow the pinna to be functional.Reference Zhu, Zhao, Wu, Lv, Bi and Sun8 In cases of tumour resections where simple closure is impossible, there are several possibilities: closure of the defect with a free graft, healing by secondary intention, or reconstruction with pedicled flaps.Reference Zhu, Zhao, Wu, Lv, Bi and Sun8
The use of retroauricular flaps is a useful and versatile alternative technique for covering defects of the conchal region involving cartilage. They are supplied by the retroauricular artery and its superior, medial, and inferior branches, which irrigate a large part of the pinna, thereby forming an anastomotic network with a large vascular supply.Reference Zhu, Zhao, Wu, Lv, Bi and Sun8 The aim of this present study was to popularise this technique which, despite having been described some time ago, is not well-known among ENT specialists.
Technique
This series included nine patients operated for benign or malignant lesions of the pinna from 2020 to 2023 in the Department of Otorhinolaryngology and Head and Neck Surgery at a University Hospital. Five of the patients were operated under general anaesthesia, and in four cases, the procedure was performed with local anaesthesia. The retroauricular area was injected with local aesthetic and a vasoconstrictor (mepivacaine + epinephrine 1:50.000) prior to incision.
Regarding the surgical technique, first, the area to be excised from the auricular concha is defined, leaving sufficient space to achieve tumour-free edges. The size of the tumour area defines the retroauricular donor area, which is located partly in the mastoid region and partly in the retroauricular area (Figures 1A and 1B). After excision of the tumour lesion, a flap is fashioned for reconstruction, applying a technique similar to that used in otoplasty. Thus, an incision is made following the previously marked line to form a flap centred on the retroauricular groove (Figure 1C). Part of the cartilage in the flap area is subsequently resected to allow mobilisation of the flap in a forward direction. It is important not to damage the skin of the posterior region of the concha because it forms part of the flap. After pediculising the flap, it is transposed forward through the cartilage to cover the defect and is then sutured with silk (Figure 1D). The wound at the retroauricular level is also closed with silk with no further manipulations.Reference Papa, Stocco and Arnež1,Reference Dubernard, Kleiber, Brenet, Louges, Veleine and Labrousse2 In all of our cases, POPE® packing was used, and a single dose of otic antibiotic therapy was given after surgery to help avoid external auditory canal (EAC) stenosis.
Figure 1. Surgical technique. A, B: Identification of lesion, delimitation of resection area and retroauricular flap zone. C, D: Creation of the retroauricular flap. E: Anterior resection area with oncological margins. F: Anterior transposition of the created flap to cover the concha, in this case the defect was 5.5cm x 5.5cm (case 7 of the table).
Since 2020, we have performed the retroauricular island flap technique in a total of nine patients (five men and four women) with an average age of 67 years (Table 1). Complete resection of the neoplastic lesion with tumour-free margins and total coverage of the defect by the retroauricular island flap was achieved in all the cases, with favourable aesthetic and functional results in the immediate post-operative period (Figures 2 and 3). After surgery, no cases of flap infection or necrosis were recorded in any of the patients, although there was one case of EAC stenosis.
Table 1. Our series group study
Figure 2. Immediate post-surgical result, anterior and posterior views.
Figure 3. Post-surgical results. A: Patient 1, one month after surgery, anterior and posterior views. B: Patient 2, one week after surgery, anterior and posterior views.
Discussion
Masson first described the RDIF technique, which would later be used by Jackson.Reference Jackson, Milligan and Agrawal9 Creation of a flap has several important advantages over free grafts, including the ability to match the graft thickness, colour, and texture with the skin of the site to be grafted; minimal morbidity; and allowing the possibility of primary closure of the donor area.Reference Stiller, Gerressen, Modabber, Rübben, Riediger and Ghassemi10 It is an easily reproducible technique that can be performed with local anaesthesia, does not require too much surgical time, and with no need to search for the flap pedicle. However, despite its advantages in terms of surgical technique and aesthetic and functional outcomes, we have found no evidence that it is popular among ENT surgeons.
The aggressiveness of malignant tumours of the pinna is directly related to the possibility of infiltration of the EAC.Reference Iljin, Antoszewski, Durko, Zieliński, Stabryła and Pietruszewska3 Among these malignant lesions, squamous carcinoma most often affects the EAC, representing up to 70 per cent of cases in some series.Reference Ouaz, Robier, Lescanne, Bobillier, Morinière and Bakhos4 Surgical treatment of tumours affecting both the pinna and the EAC is a challenge because reconstruction of the latter requires a patency with a minimum diameter of 4 mm to be maintained.Reference Shaari, Xing, Mundi, Khorsandi, Geronemus and Urken11 In these cases, the RDIF technique can be used alone or as a complement to another reconstruction approach, given its versatility in terms of shape and size to cover conchal defects larger than 6 cm.Reference Clark and Hanke5
Possible complications of RDIF are necrosis, infection, recurrence or metastasis.Reference Zhu, Zhao, Wu, Lv, Bi and Sun8 The academic literature also describes cases of posterior retraction of the auricular pavilion (especially in patients with large pinnae), although the elasticity of the tissues allows resolution of this problem in the long term. Nonetheless, in the case series reported here, none of these complications occurred.
Conclusion
RDIF reconstruction is an easily reproducible and reliable technique that allows the reconstruction of auricular concha defects to achieve both aesthetic and functional objectives. Its use offers great advantages over other reconstructive techniques, which is why we believe its use by ENT surgeons should be revived.
Competing interests
The authors declare no potential conflicts of interest.
Financial disclosure
None.
Level of evidence
4. Case series
