Case Report
Rotation Flap Post Auricular Cutaneus Mastoid Defect
Presentator : dr. Erizal Salam Putra
Advisor : dr. Ramlan Sitompul, Sp. THTBKL., Subsp. FPR.(K)
Moderator : dr. Carlo Maulana Akbar, Sp. T.H.T.B.K.L., M.Ked(ORL-HNS)
Examiner : 1. dr. Ashri Yudhistira, Sp. T.H.T.B.K.L., Subsp. Onk.(K), M.Ked(ORL-HNS) FICS 2. dr. Yuliani M. Lubis, Sp. T.H.T.B.K.L.
Day / Date : Wednesday / Juni 19th 2024
Time : 09.00 – 10.00 A.M
Place :
Meeting Room of ENT Department RSUP H. Adam Malik Medan
OTORHINOLARYNGOLOGY- HEAD AND NECK SURGERY DEPARTMENT FACULTY OF MEDICINE UNIVERSITY OF NORTH SUMATERA
Introduction
In reconstructive surgery, flap design and transfer is an important skill to close tissue lesions that are generally unsuitable for suturing. The range of tissue defects that can be found in patients, from small defects of the skin alone to large defects of various tissue types, and the various etiologies can occur, including congenital, oncologic and traumatic, require a diverse set of competencies that need to continually evolve as new techniques and mechanisms of injury emerge. Proficiency in a traumatic soft tissue surgical techniques and an understanding of the anatomy and physiology of the defect as well as the likely donor site are essential for a successful flap transfer procedure (Saber, 2022).
Tumorigenesis, trauma, and infection are the three main causes of postauricular skin defects. Postauricular cutaneous mastoid fistula (PCMF) is a rare complication of cholesteatoma and an unusual consequence of chronic suppurative otitis media (CSOM). This fistula connects the mastoid cavity with the postauricular skin. Fistulas are also known to cause complications in extensive mastoidectomy and meatoplasty, especially after multiple postauricular incisions and poor wound healing (Olusesi, 2014; Zhang, 2016).
Excision of the fistula tract and obliteration of the mastoid cavity is an effective treatment for post-aural fistula after Canal Wall Down (CWD) mastoidectomy. After CWD surgery, the mastoid cavity may drain in 10-66% of cases. Once the CWD process is complete, the cavity will be polished using a diamond bur, which will smooth the cavity, but impair its ability to regenerate epithelium by devascularizing it. If a vascular pedunculated graft is applied, the size of the exiting surface will be significantly reduced after culling of the cavity, and regeneration of the remaining surface epithelium will be preserved. After obliteration, the cavity begins to improve more rapidly. The main drawbacks of cavity obliteration are potential distant brain problems and failure to detect cholesteatoma recurrence in a timely manner (Khatri, 2021).
In addition to the discomfort associated with post-aural discharge, patients with PCMFs often seek medical attention for aesthetic purposes. Although the incidence of bilateral PCMF has been documented to aggravate cholesteatoma, PCMF is usually unilateral. When PCMF complicates cholesteatoma, a ventilating mastoid fistula is thought to act as a natural way to prevent the development of fatal intracranial problems (Olusesi, 2014; Khatri, 2021).
A suitable flap can be selected from the retroauricular skin flap bank to repair the defect on the anterior surface, lobule, or, in rare cases, free margin. Some papers have discussed the use of rotating flaps to repair the postauricular surface, but the retroauricular artery perforator-based island flap is considered a useful regional flap to treat abnormalities of the temporal area, helical rim, and concha. There are not yet sufficient details regarding the consistent blood supply of the perforator to the flap (Zhang, 2016).
In addition, problems such as necrosis, disintegration, and fistula formation may occur if the skin border of the postauricular incision is not properly cared for. Fistulas may recurrent because spontaneous healing is less likely when necrotic tissue is present at the fistula border.
Secondary wound healing can also be accomplished with antibiotic ointment dressings, but this procedure is labor intensive and may cause discomfort. For this reason, surgical closure is recommended in these cases. Many approaches to PCMF closure have been reported in the literature (Askari, 2023). Here, we report a case of surgically resolved PCMF.
Case Report
The patient came to the facial plastic reconstruction division on 11th Jule 2023 with complaints of a retroauricular suture wound that did not closed. Currently there are complaints of fluid coming out of the left ear. The patient was a post-radical mastoidectomy at 24th June 2023. On physical examination, the patient was found to be in good general condition with compos mentis consciousness, blood pressure within normal limits (110/80mmHg), heart rate within normal limits (85x/min), normal breathing (22x/min) and normal saturation at room air (SpO2: 99%).
On examination of the right ear, the auricle was found to be within normal limits, the ear canal
Figure 1: The patient's condition when he first came for consultation at the maxillofacial clinic
Figure 2: The patient's condition when he first came for consultation at the maxillofacial clinic
On laboratory examination 18 th December 2023, Hb, leukocytes and platelets were found within normal limits (16.2/6,600/227,000), electrolyte examination results were within normal limits (Na/K/Cl: 148/4.1/107) and renal function examination results were within normal limits (Ur/Cr: 23/1.05) and liver function was within normal limits (SGOT/SGPT: 30/45). 05) and liver function was within normal limits (SGOT/SGPT: 30/45), while blood sugar level was within normal limits (154 mg/dl) and hemostasis function values were within normal limits
(BT/PT/aPTT/TT: 3.3/10.9/30.3/16.5). Postero-anterior chest radiograph examination was performed on 18 th December 2023 and we found cardiomegaly, but the lungs within normal limits.
Figure 3. Cardiomegaly. Lung x-ray within normal limits
The patient was hospitalized on 19 th December 2023 and gets a crystalloid infusion, antibiotics ampicillin sulbactam, H2 receptor blocker (Ranitidine) and antifibrinolytic (tranexamic acid). On 20th December 2023, surgery was performed under general anesthesia.
After performing septic antiseptic procedures and draping. We marked the defect area before the incised.
Figure 4. Septic and antiseptic
Then, infiltration was performed in the area to be incised, followed by an incision at the edge of the marked retroauricular fistula.
Figure 5. Infiltration and incision of the fistula
Next, markings were made on the area of the fistula that will be closed. Then, the marked area was infiltrated and the incision formed a flap on the posterior pinna near the retroauricular fistula.
Figure 6. Marking, infiltration, and flap incision.
Afterwards, the flap was sutured to cover the retroauricular fistula defect. Evaluation of the wound edges and bleeding was performed. A sofratulle and sterile bandage was applied to cover the wound.
Figure 7. Flap suturing to close the fistula
After surgery, the patient was hospitalized with a 300 head position, and was given antibiotics, anti-inflammatories, painkillers, antifibrinolytics, and H2 receptor blockers.
The first day after surgery, the patient complained of ear pain with a VAS score of 5. On physical examination, the patient was found to be in good condition with compos mentis consciousness, blood pressure within normal limits (130/80mmHg), heart rate within normal limits (84x/min) and normal breathing. (22x/min) and saturation within normal limits using room water (SpO2: 99%). Examination of the right ear revealed normal earlobe, wide ear canal, intact tympanic membrane and bandage covered left ear, minimal blood seepage (+). The patient then underwent outpatient treatment on day 2.
Figure 8. Wounds on the first day of post surgery
On December 27th 2023, the patient came for postoperative control on the 7th day. On physical examination, the patient was found to be in good general condition with compos mentis consciousness, blood pressure within normal limits (120/80mmHg), heart rate within normal limits (85x/min), normal breathing (20x/min), and normal saturation (SpO2: 99%). Examination of the right ear revealed normal earlobe, wide ear canal, intact tympanic membrane and bandage covered left ear, blood seeping (-). Sutures were removed, ointments and oral antibiotics were administered. The patient was instructed to control on January 2nd 2024.
\ Figure 9. Ear’s Condition after removed the hecting
normal limits, the pre-auricular suture was dry, blood (-) pus (-), the ear canal was wide, visible blood clots (-), active bleeding (-).
Discussion
Skin is the largest organ in the human body and is often the most overlooked. The integumentary system serves as the ultimate canvas for plastic surgeons, and its surface can only be properly camouflaged with an intricate knowledge of its form and function. The skin has an important protective function as the first barrier against potential hazards such as infection or trauma, and its contiguous structures envelop and largely define most of the human body (Sataloff, 2016). In order from outside to inside, the skin consists of the epidermis, dermis, and subcutaneous tissue. The layers of the skin are traditionally described, in dermatology texts, from deep to superficial. This is intuitive in the sense that the development of cell structures starts from the basal layer and progresses to the surface. However, this chapter will take an alternative approach and describe anatomical elements from superficial to deep as this is the method used by surgical practitioners to locate these components. When trying to understand the concept of the skin anatomy, it is best to think of the entire system as a map and each layer as a road that gives you access to the various structures. Figure 1.1 provides an overview of the overall gross structure of the skin from a depth perspective (Sataloff, 2016).
Figure 10. Skin Structure
The skin is fed by the subdermal plexus, which sends vertically oriented perforating blood vessels upward through the layers of the dermis: the deeper reticular dermis and the shallower papillary dermis. Underneath the papillary dermis is the epidermis, which consists of the following layers, from deep to superficial: stratum basale, stratum spinosum, stratum granulosum, and stratum corneum. If the subdermal plexus is injured during flap removal, either the arterial or venous component, the tissue will most likely die as it will be too thick to serve as a free skin graft; the subdermal plexus is located within the subdermal fat or deep within the reticular dermis itself (Prohaska, 2023).
Within the face, there are three other concepts that are important to understand in order to plan a flap transfer in a cosmetically acceptable manner: the relaxed skin tension line (RSTL)
perioral area, and chin; some of these, such as the nose and periorbital area, are subdivided into smaller subunits, the boundaries of which can also be used to hide the incision (Prohaska, 2023).
Mastoid fistulas may occur as a secondary result of a mastoid abscess or otitis media.
Chronic suppurative otitis media (CSOM), including tuberculous otitis media, is the underlying etiology of these cases. Some previous studies reported squamous variant CSOM and non- specific CSOM. Recently, the concurrent occurrence of squamous cell carcinoma of the middle ear and PCMF has been reported. PCMF may also develop as a result of a ruptured mastoid abscess, cholesteatoma, or post-mastoidectomy. Vira et al identified four patients treated for PCMF, all occurring post mastoidectomy. Similar surgical techniques were applied for these patients, including a two-layer closure of the fistula tract, using two rotational flaps of temporalis muscle and conchal cartilage (Pendolino 2019; Askari, 2023).
The method to closed the postauricular cutaneous mastoid fistulas can be challenging for otologic surgeons. The size of the fistula and the extent of skin necrosis in these cases cause problems with direct wound closure. Skin tension caused by skin loss can lead to skin necrosis and recurrent fistula postoperatively. Pendolino et al. used a bilobed flap to treat a patient with a postauricular mastoid fistula and a history of tympanoplasty for cholesteatoma recurrence. They filled the mastoid cavity with a fibro-muscular-periosteal flap region and used a bilobed flap to reconstruct the skin defect (Priyono, 2021).
Rotational flaps should be used when other simpler types of closure fail to provide adequate functional or cosmetic results. Rotational flaps, regardless of their length and curvature, can be used in many locations. They are most commonly used for lesions on the lateral face, cheeks, chin and scalp. Rotational flaps are particularly useful for directing tension around the free margin to prevent distortion. Examples of this application include eye brow and lips reconstruction. There are also some named rotational flaps, such as the Tenzel and Mustardé flaps, which are useful in certain situations that will be discussed below (Prohaska, 2023).
In addition to the indications of rotational flaps, it is also important to consider the contraindications of these flaps. The flap is contraindicated if the existing malignancy is not completely cleared. Failure to achieve clear margins before performing the flap can have disastrous consequences. Residual tumors may grow unrecognized under the flap for years. The tumor may spread along the undermined plane, which may further add to the morbidity of the
malignancy. Relative contraindications to rotational flap transfer include increased risk of bleeding and active smokers. Smokers, in general, have a higher risk of developing complications after surgery. In particular, they have a higher risk of flap necrosis, which means that other closure options may be preferable. Smokers should be advised to quit or reduce smoking before and after the procedure to help maximize flap survival. Patients on anticoagulant therapy have a higher risk of perioperative and postoperative bleeding, which may also compromise flap survival. The current recommendation is to continue prescribed anticoagulant therapy for patients undergoing skin procedures. Surgeons should be mindful of this risk in planning wound closure to help reduce the likelihood of adverse effect (Lewis, 2008; Prohaska, 2023).
Rotational flaps are elevated using arcuate or curvilinear incisions. Although referred to as a rotational flap, in practice, it combines advancement and rotation to rotate the flap in place.
Due to its curved shape, the solitary rotation flap is ideal for closing triangular defects. If a circular defect is closed with a single rotation flap, the defect should be enlarged to an isosceles triangle along the arc of tissue movement before flap advancement. The apex of the triangle should point towards the center of the arc, and the base of the triangle should be continuous with the arc of the flap. The isosceles triangle should ideally have a length twice the width of the base of the triangle. If the primary defect is not enlarged into a triangle, additional skin deformity will occur at the pivot point of the flap. In contrast, closure using multiple rotation flaps does not require enlarging the primary defect into a triangle (Prohaska, 2023).
Rotational flaps are unique in that they are subject to a tethering effect known as pivotal restraint. Due to this phenomenon, rotational flaps can fail because they do not completely cover the most distal edge of the primary defect. The pivotal restraint point, located at the end of the
should be taken in undermining, as excessive undermining may separate the pedicle from the perforating artery that supplies it (Bailey, 2014; Prohaska, 2023).
Very important restraints should be considered in the planning stage of the flap. Essential restraint is overcome by making the radius of the bow greater than the length of the defect.Some authors suggest the radius should measure 1-2 times the length of the defect. This increase in radius makes the arc higher than the defect and effectively compensates for the loss of length that occurs when the flap is rotated. Another option is to add more advancement components to the flap. However, this will increase the closing tension, which may interfere with the blood vessel supply to the flap tip. Finally, adding a back cut to the end of the incision brings the pivot point closer to the primary defect and usually reduces pivot restraint. However, the back cut will reduce the width of the pedicle, which may interfere with the vascularization of the flap. Tissue mobility is proportional to the length of the back cut, so the surgeon must balance the need for additional movement with the size of the pedicle. The rule of thumb for random pattern facial flaps is to keep the pedicle length:width ratio less than 4:1. The face is well-vascularized and, therefore, can support flaps of this length; however, flaps located elsewhere on the body should have a length:width ratio of less than 2:1 (Prohaska, 2023).
The arc angle should be greater than 90 degrees to distribute the tension properly.
Extension of more than 90 degrees has minimal effect on decreasing tension but has the potential to reduce the size of standing skin abnormalities. Ideally, the arc of the rotational flap should be between 90 to 180 degrees. Rotational flaps with an arc less than 90 will experience higher tension at closure. Conversely, arcs greater than 180 degrees alter the tension vector in a counter- productive manner, typically adding tension in a vector parallel to what would occur in primary wound closure (Prohaska, 2023).
The tension vector for a rotational flap is directed perpendicularly along the arc of the incision, which in a classic rotational flap, is perpendicular to the tension vector for primary wound closure. For most other flaps, the area of greatest stress is at the secondary defect closure.
For pure rotational flaps, the maximal stress is directed perpendicular to the arc of rotation, 90 to 135 degrees from the defect. If there is an advancement component to the flap, the point of maximal stress will be at the tip of the rotational flap. For larger defects, the length and curve of the incision required for flap removal may run perpendicular to the relaxed skin tension line or
cross over into other cosmetic units, which can be a limiting factor in the use of rotational flaps.
However, the length of the incision can be used advantageously to recruit distant tissue or to conceal standing cone deformities in less aesthetically sensitive locations. A good example of a rotational flap used for aesthetic purposes is the facelift, which uses a large rotational flap to re- lift and smooth the soft tissues of the face (Prohaska, 2023).
Due to the primary motion of the rotational flap, a standing skin deformity may result at the end of the arc opposite the defect, on the outside of the curve. In some cases, especially in longer incisions, the length difference between the cut edges of the skin on the inside and outside of the curve can be halved using sutures to compress and distribute excess tissue along the wound (Prohaska, 2023).Complications of rhombic flap reconstruction should be fully described during the consent process and can be divided into general and specific complications. General complications include pain, bleeding, infection, wound breakdown, scarring (including abnormal ones). Specific complications of partial or complete flap failure are rare and can be caused by surgical factors such as excessive thinning and flap breakage.
This may be influenced by patient factors such as smoking. In addition, tension distribution and lymphatic drainage can be causing aesthetically significant protrusion or dog- ear, as well as 'pin-cushion' deformity and tethering of adjacent structures. There is also a risk of damage to the underlying structures specific to the anatomical region involved. The importance of the underlying structures must be fully explained. For example, if one is performing surgery on the temporal region, the potential disruption to the motor function of the temporal branch of the facial nerve should be explained (Hon, 2020; Macneal 2022).
DAFTAR PUSTAKA
Askari, Mehdi. 2022. “Postauricular Cutaneous Mastoid Fistula Surgically Closed by a
Temporalis Muscle Rotational Flap: A Case Report.” Disease and Diagnosis 12(3): 151–53.
Bednarek RS, Campos MS, Hohman MH, Michael LR. 2022. "Transposition flap". NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing
Hon, Heidi H., and Srinivasa Rama Chandra. 2020. “Rhomboid Flap.” Atlas of the Oral and Maxillofacial Surgery Clinics of North America 28(1): 17–22.
https://doi.org/10.1016/j.cxom.2019.11.005.
Khatri RP. 2021. "A case study of post-auricular persistent mastoid cutaneous fistula closure by anteriorly based temporalis muscle flap and tempero-mastoid fascio-cutaneous-periosteal flap". International Journal of Otorhinolaryngology and Head and Neck Surgery. DOI:
https://dx.doi.org/10.18203/issn.2454-5929.ijohns20213298.
Macneal P, Adlard RE. 2022. "Rhombic Flaps". NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health. StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing
Olusesi, Abiodun Daud, and Emmanuel Opaluwah. 2014. “Postauricular Advancement Fascio- Cutaneoperiosteal Flap for Closure of Mastoid Cutaneous Fistula.” Otolaryngologia Polska 68(5): 276–80. http://dx.doi.org/10.1016/j.otpol.2014.02.001.
Pendolino AL, Pavone C, Zanoletti E. 2019. "Fibro-muscular-periosteal flap and bilobed flap for post-auricular cutaneous mastoid fistula closure". The Journal of Laryngology & Otology.
1–4. https://doi.org/10.1017/ S0022215119001063
Priyono H, Restuti RD, Sriyana AA, Saleh RR. 2021. "Postauricular Cutaneous Mastoid Fistula Closure with Combination of Bilobed Flap and Fibro-Muscular-Periosteal Flap: A Case Series". Indian J Otol 2021;27:116-9.
Prohaska J, Campos MS, Cook C. 2023. "Rotation flap". National Library of Medicine, National Institutes of Health. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing
Saber, Ahmed Y, Marc H Hohman, and Mark A Dreyer. 2023. “Basic Flap Design.” : 1–12.
Zhang, Yuan Zheng et al. 2016. “Reconstruction of the Postauricular Defects Using Retroauricular Artery Perforator-Based Island Flaps Anatomical Study and Clinical Report.”
Medicine (United States) 95(37).
