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Thread: Excision of Auricular Squamous Cell Carcinoma pictures - Ear Atlas

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    Default Excision of Auricular Squamous Cell Carcinoma pictures - Ear Atlas

    Indications
    Reconstruction of the ear is indicated when a defect is present after skin cancer extirpation. The reconstruction methods discussed in this article all follow the principles of Mohs micrographic surgery. Certain small defects may not need reconstruction and can heal by second intention. This concept is also discussed below.

    Relevant Anatomy
    The external ear is composed of skin and cartilage with the supporting nerves and blood vessels. The auricular cartilage provides a framework for the entire ear except the lobule. The tightly adherent skin extending from the preauricular sulcus to the helix produces distinct topographical landmarks on the anterior surface of the ear that are important in understanding and describing the ear (see the first image below). The concavities include the triangular fossa, the scapha, the cymba, and the cavum of the concha. The helix, the antihelix, the tragus, and the antitragus form the convexities. The skin on the posterior (medial) aspect of the ear that extends to the postauricular sulcus is less adherent to the underlying cartilage (see the second image below)

    A well-proportioned ear is 50-60% as wide as it is high. The ear is positioned one ear length from the lateral orbital rim, and the top of the ear is level with the eyebrow and tilted back by 20°.

    The auriculotemporal nerve, a branch of cranial nerve V3 innervates the superior aspect of the anterior surface of the ear. The lesser occipital nerve and the great auricular nerve are both derived from C2 and C3. The lesser occipital nerve innervates the superior aspect of the posterior surface. The great auricular nerve innervates the lower portion of both surfaces. The vagus nerve supplies the concha.

    The ear is well vascularized, an important feature because most flaps are based on a random blood supply. The superficial temporal artery and the posterior auricular artery are branches of the external carotid artery and supply the anterior and posterior surfaces, respectively. Because of the rich blood supply and collateralization, anesthetics that contain epinephrine can be used safely.

    Contraindications
    Reconstruction of the ear has relatively few contraindications. If the patient can tolerate the initial Mohs micrographic surgery, they can usually tolerate the subsequent reconstruction as well, although the complexity of the reconstruction may need to be tailored to the patient's medical state. In patients whose medical condition precludes surgery, other treatment options, such as irradiation, should be considered.
    Excision Auricular Squamous Cell Carcinoma attachment.php?s=aa6a97638ac8994196ebdb5b03939e8e&attachmentid=1840&d=1441384977

    The patient's medical history should be assessed prior to surgery. Aspirin and warfarin increase the risk of intraoperative and postoperative bleeding complications. The use of these medications is not an absolute contraindication for skin surgery, but stopping these treatments prior to surgery is ideal, if possible.

    Surgical Therapy
    Flaps, grafts, and primary linear closures can be used in reconstruction of the ear. Healing by second intention is also a valuable tool. The reconstruction technique best suited for a given defect is determined by the size and location of the defect. The goal of reconstruction is to restore the shape, size, and alignment of the ear.

    An important principle in ear reconstruction is that the entire anterior surfaces of both ears cannot be viewed simultaneously. Therefore, reconstructing the ear so that it is not distorted or deformed is important, but one ear does not have to exactly match the contralateral ear in terms of its size and appearance. The ear also has a functional importance for many patients as a supporting structure for eyeglasses.

    The defects addressed below can occur as a result of Mohs micrographic surgery to treat skin cancers. The reconstructions are categorized on the basis of the anatomic location of the defect. The regions are divided into the helix, the anterior surface, the posterior surface (preauricular sulcus and postauricular sulcus), and the lobule.

    Anterior surface defects
    The triangular fossa, the scapha, the antihelix, and the concha are the regions inside the helical rim. Defects in these regions must be assessed for involvement of only the skin, the skin and perichondrium, or the skin and cartilage. Skin grafts are useful in covering a wide variety of ear defects. If the perichondrium is present, a full-thickness skin graft can be applied. Depending on the size of the defect, the common donor sites are the contralateral postauricular sulcus or the supraclavicular skin.

    Split-thickness skin grafts (STSGs) can also be used, although the color and texture match may not be as good as with other methods.STSGs have an advantage in that they can survive even if the entire perichondrium is not intact. If no perichondrium is present, the cartilage can be excised to reveal the posterior skin of the ear. For most defects within an intact helix, enough structural support is present even without the cartilage. A graft can be placed on this vascular bed (see the image below). Grafts placed in the concha should be generously sized to compensate for the profound concavity.

    Although the postauricular sulcus becomes narrower than the contralateral ear, it typically does not appear asymmetric from either the frontal or the posterior views. If tacking back of the ear is too excessive for the patient, the wound edges can be pulled slightly apart at the time of suture removal and allowed to heal by secondary intention.

    Split bilobed flaps have been used to repair composite posterior auricular and mastoid defects.

    Lobular defects
    Defects of the lobule and lower helix can be repaired with either a primary linear closure for partial-thickness defects or wedge excision for full-thickness defects. Defects involving as much as 50% of the lobule can be repaired in this fashion (see the image below). To prevent notching or separation, wound eversion is important.
    Excision Auricular Squamous Cell Carcinoma attachment.php?s=aa6a97638ac8994196ebdb5b03939e8e&attachmentid=1841&d=1441384990

    Defects on the superior and mid helix can be repaired with a bilobed flap. Ideally, the cartilage should be intact, but the flap has enough bulk to offset a small cartilage defect. The loose postauricular skin is easily undermined and serves as the donor site for this flap. The classic bilobed flap has a base that is 180°, with 90° between each lobe. This flap can be modified to decrease the angles between the lobes to reduce the movement and the size of the dog ears (see the images below). The pivot point of the flap must be understood to enable correct measurement of the appropriate length and width of the flap. Defects as large as 2 cm can be repaired with a minimal reduction in the size of the ear.

    Defects on the superior aspect of the helix are ideal for repair with the banner transposition flap. Originally described with use of the postauricular skin, the loose preauricular skin can also serve as the donor site for the flap (see the image below). The base of the flap is superior and contiguous with the defect; this construction allows for the flap to be draped onto the defect. To preserve a wide flap base, the posterior dog ear must be removed with an incision away from the base. This flap can be used only for defects of the skin or for defects of both the skin and cartilage.

    Defects confined to the helix with or without a cartilage defect can be repaired with the chondrocutaneous advancement flap, or Antia-Buch chondrocutaneous advancement flap. This flap is used for moderate-sized defects on the helical rim. The skin of the helix and the underlying cartilage are either unilaterally or bilaterally advanced.

    The flap has 2 variations. In the first, the flap can be of full thickness and detached on both the anterior and posterior surfaces of the helix. This construction allows for maximal extension of the flap, although the flap pedicle is relatively narrow. (In the second, the flap can be designed with the posterior skin intact, leaving a broader flap base as Antia and Buch originally describe. The entire posterior skin is undermined to elevate the flap. Then, the flap is advanced with a dog ear that is removed posteriorly (see the images below). The helix must be meticulously realigned.

    References:
    http://emedicine.medscape.com/article/1129708-treatment











    Last edited by Medical Photos; 09-04-2015 at 04:43 PM.

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    Default Excision of Auricular Squamous Cell Carcinoma pictures Ear Atlas

    Is the squamous cell carcinoma excised from the right upper abdominal wall a metastasis from either the prior squamous cell carcinoma on the neck or its suspected unknown primary? If so, wouldnt you code from the Malignant, Secondary column of the Neoplasm table, 198.2 ?

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