New Techniques Basal Cell Carcinoma with unusual location in the ear-surgical reconstruction

The skin flaps are surgical techniques particularly useful to aesthetic repair in cases of extended excision and/or unusual sites, as in the ear. Many skin flaps options were already reported, resulting in variable results of the theoretical knowledge and practical experience of the surgeon. This article aims to describe two successful cases of ear reconstruction with the use of anterior and posterior flaps and to review the current literature.


RESU MO
Retalhos cutâneos constituem técnica cirúrgica particularmente útil para reparos estéticos nos casos de excisões extensas e/ou lesões de localizações peculiares, como a orelha.Diversas opções de retalhos cutâneos já foram descritas, determinando resultados variáveis que dependem do conhecimento teórico e da experiência prática do cirurgião.O objetivo deste artigo é relatar dois casos de sucesso com a utilização das técnicas de retalhos anterior e posterior para reparação da orelha e revisar a literatura afim.Palavras-chave: retalhos cirúrgicos; orelha; carcinoma basocelular area difficult to manipulate, the surgical reconstruction in that region is challenging.Basal cell carcinoma (BCC) is a common cutaneous neoplasm whose excision does not always allow primary closure of the surgical incision, especially in the ear.In this paper, the authors describe their experience with the reconstruction of the triangular fossa -a branch of the anti-helix and concha -after excision of BCC, employing flaps originated from similar cosmetic units using two different techniques.

Case 1
A 46 year-old male patient who did not have comorbidities bore a lesion in the auricular anti-helix with approximately 3cm in diameter in its longest axis and that was clinically suggestive of BCC.

Anterior auricular flap surgical technique
After both the lesion to be excised (Figure 1) and the pre-auricular flap were marked, local anesthesia and regional block were carried out with 2% lidocaine, epinephrine and 8.4% sodium bicarbonate solution.
The removal of the nodular lesion located in the triangular fossa was performed using curettage followed by spindle excision up until the cartilage was exposed (Figure 2).
Next, the flap was prepared in the pre-auricular region (Figure 3).The transection of the helix by the flap's pedicle and subsequent positioning on the open area was performed via an incision in the helix's skin and cartilage (Figure 4).Suture with 5.0mm mononylon thread for internal stitches was then carried out, followed by a simple suture for attaching the flap to the receiver area.The surgery was completed with the primary closure of the donor area in the anterior auricular region (Figure 5).
The pedicle resection and the defect closure was carried out in a second surgical time using 5.0 mononylon thread.

Case 2
A 83-year-old male patient with chronic obstructive pulmonary disease had been bearing a pruriginous ulcerated lesion located at the auricular concha for 8 months.The lesion

Posterior auricular flap surgical technique
The excision of the lesion located in the auricular concha was performed similarly to that described in Case 1.
In Case 2, however, the flap was originated from the retroauricular region, having been transfixed through the concha's cartilage, aimed at accommodating the flap in the receiving area (Figure 6).The suture was the carried out for attaching the flap in the receiving bed and primarily closing the donor area.The resection of the pedicle and closure of the defect were performed in the second surgical time (Figures 7 and 8).

RESULTS
Both ear reconstruction techniques were successfully performed with absence of complications, leading to excellent aesthetic and functional outcomes, based on the use of flaps prepared using both the anterior and posterior regions.
In both cases, the pathological examination's result of the surgical specimen evidenced BCC with free margins.

DISCUSSION
The use of flaps for reconstructing the ear after the excision of tumors is the most indicated technique, for direct closure is not feasible and grafts are difficult to adhere to this region. 1,23][4] Among the sites compatible for ear reconstruction, the pre-auricular 5 and posterior auricular areas, as well as the retroauricular sulcus and the mastoid region stand out. 3,4nterpolation flaps are performed by shifting the tissue to a nearby -but not contiguous -receiver area. 1 This technique was chosen due to the possibility of better local vascularization and aesthetic outcome, as compared to the second-intention closure. 2,6espite being the first choice in the reconstruction of the concha, the posterior flap's interpolation technique (or Masson's flap), firstly described in 1972, is a high-risk procedure. 6The tissue tends to allow only a narrow pedicle, and performing the rotation inside the ear hampers local blood circulation. 6Stemming from these characteristics, complications, such as necrosis, might arise. 7Nevertheless, the literature does not highlight the need to preserve the posterior auricular artery's pedicle and suggests that the preservation of 50% of the flap's vascular pedicle is sufficient for its viability. 7n this flap type, special attention should be given to the second surgical time 3 weeks after the primary approach, making possible proper revascularization, adhesion and viability of the transferred tissue. 2 This caution was observed in the reported cases.The need for the second surgical time is however a limiting factor for patients with low adherence to the treatment, with the risk of loss of follow-up. 8As a consequence, the need for an additional intervention after the first surgery should be explained to the patient.
The pre-auricular region's flap was initially described by Pennisi and is also an option when it is not feasible to use retroauricular flaps (for instance, when there is a tumor in this region). 9.9 Due to the use of similar aesthetic units (skin with similar color and texture), this technique leads to a good aesthetic outcome and preserves the anatomy of the ear pavilion by maintaining its natural curvature. 8,10

CONCLUSION
The anterior and posterior ear flaps techniques should be part of the therapeutic armamentarium for the correction of larger surgical defects arising from the removal of extensive tumoral lesions, preserving the site's anatomy, functionality and aesthetics.l

Figure 1 :Figure 3 :
Figure 1: Marking of the area corresponding to the basal cell carcinoma

Figure 4 :Figure 5 :
Figure 4: Detail: opening in the cartilage for sliding the flap

Figure 2 :
Figure 2: Surgical defect after the removal of the tumor

Figure 6 :
Figure 6: Marking of the retroauricular flap