New Orleans — The convoluted nature of the ear can make surgical repair of wounds a daunting challenge. However, dermatologists who take a tactical approach, understanding the wound itself, patient preference, and closure options often get good cosmetic results, according to Edward B. Desciak, M.D., at the 63rd Annual Meeting of the American Academy of Dermatology (AAD) , here.
Laying the groundwork There are three general concepts to consider initially when determining how best to approach closing an ear wound.
Dermatologists should first consider the wound.
Adequate granulation comes from an intact perichondrium, the thin, wispy layer just above the cartilage, he says.
A good way to test for adequate granulation, according to Dr. Desciak, is to gently pinch the base of the wound with forceps. Having something to pinch probably means that there is enough perichondrium to allow the wound to granulate. In the absence of enough perichondrium, dermatologists may think about making fenestrations through the cartilage in order to get a granulation source from the posterior skin. Dr. Desciak makes 2 mm punch biopsies for the fenestrations.
"Then, if cartilage is broken, I have the patient do ascetic acid or vinegar soaks to help prevent infections. Some doctors use antibiotics," he says.
While contracture should not be an issue when the wound is on the interior portion of the ear, it might be more disfiguring for patients when wounds are involving the helix or the lobe. Additionally circumferential wounds, around the external canal, may cause stenosis after contracture, signaling the dermatologist to think hard before using secondary intention.
"The advantage of secondary intention is that it is the easiest at the time of the surgery for the patient and surgeon, but it could lead to extra woundcare, more postoperative visits for the patient and a longer postoperative period," Dr. Desciak says.
Closure options start with the primary closure, which, according to Dr. Desciak, usually offers the best cosmetic result and least amount of woundcare for the patient, as long as there is adequate tissue movement and skin laxity.
The keys to primary closure, according to Dr. Desciak, are to make sure that Burrows triangles are extended long enough on the helix so that the silhouette can be nicely preserved.