Chapter 22: Middle-Third of the Helical Rim

INTRODUCTION

The middle-third of the helical rim is a common site for skin cancer. Helical rim defects can be challenging to repair given the importance of recreating the helical contour.¹ There is minimal tissue laxity, which makes side-to-side closure difficult unless the defect is small. Often, helical rim advancements and wedge excisions recreate the normal ear contour and produce great cosmetic outcomes; however, these options can reduce the size of the ear.

Full-thickness skin grafts or second intent healing are options for superficial defects but may alter the helical rim contour. Two-stage interpolation flaps are also a reliable option when there has been substantial loss of skin with or without cartilage localised to the middle-third of the ear. Combination repairs, utilising several repair options, are also useful for larger defects involving other cosmetic subunits.

SECOND INTENTION

Advantages

• Simplest option²

• Minimal operating time

• No need for sutures

Disadvantages

• Longer healing time

• Unpredictable aesthetic results

• Risk of rim notching

• Risk of infection, bleeding and chondritis

Technique

1. Second intention healing requires adequate tissue perfusion. If cartilage is exposed, an intact perichondrium is required to support granulation tissue formation. If the perichondrium is compromised, cartilage can be removed or fenestrated with a punch tool to allow for blood supply from the posterior ear.

2. Meticulous haemostasis reduces the risk of postoperative bleeding.

3. Pseudomonas is a common coloniser of the ear. Consider daily acetic acid 5% soaks (1 tablespoon of white vinegar in a cup of cooled boiled water applied with a saturated cotton ball or gauze) or gentamicin ointment. This can minimise the risk of infection.

4. Provide explicit wound care instructions to the patient including keeping the wound covered with ample petrolatum ointment and a dressing until healed over.

WEDGE REPAIR

Advantages

• Restores normal ear structure³

• Ideal for defects smaller than 1 cm and involving the antihelix

Disadvantages

• Decreases the size of the ear

• Rim notching is a risk

• Buckling of cartilage is a risk—minimised by using a modified wedge (see Fig. 22.1)

• Can produce cartilaginous prominences which may develop chondrodermatitis over time