Retrospective Review of Reconstructive Methods of Conchal Bowl Defects Following Mohs Micrographic Surgery

The revolving door flap could be the reconstructive procedure of choice for the auricular concha following skin cancer excision, based on low risk of necrosis, infection, and postoperative hemorrhage and excellent aesthetic outcomes.

“Qualitative synthesis of the results concluded that the revolving door flap could be the reconstructive procedure of choice for the auricular concha, following skin cancer excision.”

Secondary intention healing predisposes patients to infection of the conchal bowl.

“secondary intention healing seemed to predispose patients to infection of the conchal bowl, as two studies with considerable sample size found cases of infection, albeit at a low incidence [2,12].”

Secondary intention healing poses a greater risk of infection compared to the revolving door flap.

“Secondary intention healing poses a greater risk of infection, as compared to the revolving door flap [2,3,4,5,6,7,8,9,12,18].”

STSG may be used as an alternative to the revolving door flap for conchal bowl reconstruction.

“STSG may be used as an alternative.”

The subcutaneous pedicle graft is a valid alternative for conchal reconstruction, as it does not cause necrosis or infection and has only a low incidence of pincushioning and postoperative hemorrhage.

“the data provided by Wines (2001) establishes it as a valid alternative, as it does not cause necrosis or infection, and only has a low incidence of pincushioning and postoperative hemorrhage [2].”

Controversy remains regarding the preauricular transposition flap because Wines (2001) reported a considerable incidence of flap failure while Zhu (2016) did not identify any cases.

“Controversy remains regarding the preauricular transposition flap, as Wines (2001) reported a considerable incidence of flap failure, but Zhu (2016) did not identify any cases of this complication [2,9].”

Not all included studies presented data on the two outcomes considered in this review.

“Not all included studies presented data on the two outcomes considered in this review [1,2,3,4,5,6,7,8,9,10,12,18].”

Futoryan (1995) and Wines (2001), the cohort studies, performed poorly in the risk-of-bias assessment, scoring 4/9 on the Newcastle-Ottawa Scale.

“In stark opposition, Futoryan (1995) [18] and Wines (2001) [2], the cohort studies, performed poorly in the risk-of-bias assessment, scoring 4/9 in the Newcastle–Ottawa Scale, [2,14,18].”

STSG was one of two techniques to present cases of all complications.

“Among the various reconstructive methods examined by the included studies, STSG was one of two techniques to present cases of all complications [2,10,18].”

FTSG caused a wide variety of complications, but these findings were discordant across studies.

“Similarly to STSG, FTSG caused a wide variety of complications; however these findings were discordant across studies [2,3,18].”

Wines (2001) noted after STSG graft necrosis in 3.9% of patients, infection in 1.3%, altered scarring in 1.4% (half pincushioning and half graft contraction), and postoperative hemorrhage in 1.3%.

“Wines (2001) noted graft necrosis in 3.9% of patients, infection in 1.3% of patients, altered scarring in 1.4% of patients (half due to pincushioning, and half due to graft contraction), and postoperative hemorrhage in 1.3% of patients [2].”

Thuile (2018) did not identify any cases of altered scarring after STSG, and Futoryan (1996) did not find any cases of infection after STSG.

“On the contrary to the findings of Wines (2001), Thuile (2018) did not identify any cases of altered scarring, and Futoryan (1996) did not find any cases of infection [2,10,18].”

Thuile (2018) documented after STSG infection in 22.2% of patients (11.1% at donor site and 11.1% at receptor site) and postoperative hemorrhage in 11.1%.

“Thuile (2018) documented some cases of infection and postoperative hemorrhage, although the incidence of these was higher than in Wines (2001): 22.2% of patients developed an infection (11.1% occurring at the donor site, and the other 11.1% at the receptor site), and 11.1% of patients suffered from postoperative hemorrhage [2,10].”

For secondary intention healing, Futoryan (1995) reported no infections, while Levin (1996) reported 7.1% and Wines (2001) reported 2.8% postoperative infections.

“Futoryan (1995) [18] reported no cases of infection, while 7.1% of patients in Levin (1996) and 2.8% of patients in Wines (2001) developed a postoperative infection [2,12].”

Aesthetic results were reported in a heterogeneous manner across included studies.

“while complications were presented in the form of incidences in all included studies, aesthetic results were reported in a heterogeneous manner [1,2,3,4,5,6,7,8,9,10,12,18].”

Wines (2001) documented postoperative hemorrhage in 2.8% of secondary intention healing cases, with no cases of necrosis or altered scarring.

“Furthermore, Wines (2001) documented postoperative hemorrhage in 2.8% of cases, but no cases of necrosis or altered scarring [2].”

The discrepancy regarding postoperative hemorrhage after FTSG could be justified by the administration of subcutaneous heparin in the majority of patients who developed this complication in Dessy (2010).

“The discrepancy regarding postoperative hemorrhage could be justified by the administration of subcutaneous heparin in the majority of patients who developed this complication in Dessy (2010) [2,3].”

FTSG seems to have a tendency to cause complications of all kinds, a propensity that negatively impacts its aesthetic outcomes.

“FTSG seems to have a tendency to cause complications of all kinds, a propensity that negatively impacts its aesthetic outcomes [2,3,18].”

The data in this review on postoperative hemorrhage and cosmesis with secondary intention healing is limited, as only one study reported on each of these.

“Nonetheless, the data in this review on postoperative hemorrhage and cosmesis with secondary intention healing is limited, as only one study reported on each of these; therefore, further investigations are required on this subject [2,12].”

The main issue with secondary intention healing seems to be the risk of infection.

“Postoperative hemorrhage incidence was low, necrosis was nonexistent, and aesthetic outcomes were mostly satisfactory; therefore the main issue with secondary intention healing seems to be the risk of infection [2,12,18].”

This review can provide a global perspective because it comprises studies from several countries conducted by different specialists.

“Moreover, this review can provide a global perspective as it comprises studies from several countries conducted by different specialists (dermatologists, otorhinolaryngologists, or plastic surgeons) [1,2,3,4,5,6,7,8,9,10,12,18].”

Wines (2001) found no cases of infection or flap necrosis with side-to-side repair, subcutaneous pedicle graft, rotation flap, or advancement flap, but a 4.0% incidence of pincushioning and of postoperative hemorrhage with the subcutaneous pedicle graft.

“Their findings showed no cases of infection, or flap necrosis, with any of the aforementioned flaps and grafts, but a 4.0% incidence of pincushioning and of postoperative hemorrhage both with the subcutaneous pedicle graft [2].”

For the preauricular transposition flap, Wines (2001) found a 16.7% incidence of flap failure while Zhu (2016) found none; both reported no infections, Wines found no altered scarring or postoperative hemorrhage, and Zhu reported aesthetically satisfactory outcomes.

“While the former found a 16.7% incidence of flap failure, the latter did not identify any cases of such an outcome [2,9]. Furthermore, both studies reported no cases of infection, and Wines (2001) also found no incidence of altered scarring or postoperative hemorrhage [2,9]. According to Zhu (2016), the preauricular transposition flap also yielded aesthetically satisfactory outcomes [9].”

Dessy (2010) recorded after FTSG a 30% incidence of partial graft necrosis, no total graft failure, a 20% incidence of postoperative hemorrhage, and a 20% incidence of external auditory canal stenosis.

“Dessy (2010) recorded a high incidence of partial graft necrosis (30%), whereas no cases of total graft failure were documented [3]. Unlike Wines (2001) [2], Dessy (2010) [3] did find a high incidence of postoperative hemorrhage (20% of patients), and of altered scarring in the form of external auditory canal stenosis (20% of patients) [3].”

Most included studies had a long follow-up period, ensuring that even long-term complications and aesthetic defects were detected.

“For instance, most included studies had a long follow-up period, ensuring that even long-term complications and aesthetic defects were detected [1,2,3,4,5,6,7,8,9,10,12,18].”

Wines (2001) found that after FTSG only 3.9% of patients presented graft failure, with no cases of infection, altered scarring, or postoperative hemorrhage.

“Wines (2001) found that only 3.9% of patients presented graft failure, with no cases of infection, altered scarring or postoperative hemorrhage [2].”

STSG should be favored over FTSG due to its comparatively lower incidence of complications and superior cosmetic results.

“Although STSG also has a proclivity to cause complications, it should be favored over FTSG due to its comparatively lower incidence of complications and superior cosmetic results [2,3,10,18].”

The preauricular transposition flap seems acceptable, as no cases of infection, altered scarring, or postoperative hemorrhage were recorded, and it was aesthetically satisfactory.

“Otherwise, this technique seems acceptable, as no cases of infection, altered scarring, or postoperative hemorrhage were recorded, and it was aesthetically satisfactory [2,9].”

All existing reconstructive procedures applicable to the auricular concha were explored in this review.

“More importantly, all existing reconstructive procedures applicable to the auricular concha were explored [1,2,3,4,5,6,7,8,9,10,12,18].”