Melanoma pp 363-388 | Cite as

Reconstruction Options for Ear and Nose Melanoma

  • Charles L. DupinEmail author
  • Julian D’Achille
  • Ian R. Wisecarver


The ear is not commonly involved with malignant melanoma. While about 20% of melanomas occur in the head and neck, only 3–20% involve the ear (about 1–4% of all melanomas). The prognosis is significantly better than mucosal melanoma (85%) at 5 years and (77%) at 10 years. Patients with positive sentinel lymph nodes had a worse prognosis (60%) at 3 years (Jones et al. Am J Surg. 206:307–313, 2013). “Wide local excision” was used with no recommended margins. Studies have been done to determine if melanoma in the head and neck area could have “wide local excisions” which are smaller less agressive than those recommended for the trunk and extremities. The current National Comprehensive Cancer Network (NCCN) Clinical Practice Guideline recommends 0.5 cm for in situ lesions; 1 cm for lesions >1.0 mm thick; 1–2 cm for lesions 1–2 mm thick, and 2 cm for lesions thicker than 2 mm. Rawlani et al. performed a study in which the margins were reduced by half (0.5 cm for lesions >1 mm; 0.5–1 cm for lesions 1–2 mm thick; and 1.0 cm in lesions thicker than 2 mm). They had 79 patients in the series with 42 cases with recommended margins and 37 with reduced margins. They found no statistically significant difference in survival in this fairly small sample (Rawlani et al. J Surg Oncol. 111: 795–799, 2015). “The American Academy of Dermatology” published recommendations in 2011 based on both evidence from prospective randomized control studies and consensus opinion:
  1. 1.

    Wide excision for melanoma is associated with reduced recurrence.

  2. 2.

    For thin melanomas, currently there is no high-quality evidence to support excisions of more than a 1 cm margin in improving survival or local recurrence rates.

  3. 3.

    For primary melanomas of any thickness, there is no evidence to suggest that margin excision of more than 2 cm provides any additional benefit in terms of survival or local recurrence rates.

  4. 4.

    The actual recommendations: In situ: 0.5–1 cm; >1 mm to 1 cm; 1–2 mm to 1–2 cm; >2 mm to 2 cm.


If these guidelines are followed, excision size in the face would leave defects between 1 and 4 cm in diameter. In the case of the ear such an excision would require complicated reconstruction (Jones et al. Am J Surg. 206: 307–313, 2013).

There is obviously still some controversy about the issue of margins and larger series are needed specifically for malignant melanoma of the face.

The primary treatment for melanoma involving the cheeks, forehead, scalp, and nose therefore remains somewhat controversial. The current National Comprehensive Cancer Network (NCCN) Clinical Practice Guideline recommends 0.5 cm for in situ lesions; 1 cm for lesions >1.0 mm thick; 1–2 cm for lesions 1–2 mm thick, and 2 cm for lesions thicker than 2 mm (Rawlani et al. J Surg Oncol. 111: 795–799, 2015). Other authors have studied reducing these margins when treating facial melanoma by ½ and in small series report no difference in survival (Cheriyan et al. J Surg Clin North Am. 94: 1091–1113, 2014). While an excision of 4 cm on the forehead or scalp is still a challenge, such an excision on the nose or cheek requires considerable reconstructive skills. Wide local excision, using whatever criteria are selected, should not be incompatible with a normal appearance.

This chapter will illustrate an approach to repairing defects between 1 and 4 cm in diameter in the ear and nose. Multiple options based on the availability of local and regional tissue will be discussed. The goal is to restore the patient’s appearance so that they can confidently go about their lives after excision of melanoma. Options such a skin grafts, flaps, local tissue rearrangement, and regional tissue transfers will be presented.


Melanoma of ear and lips Wide local excision Techniques for functional repair Facial melanoma Appropriate therapy Avoidance of deformity 


  1. 1.
    Soong S-J, Weiss HL. Predicting outcome in patients with localized melanoma (Ch. 3). In: Balch CM, Houghton AN, Sober AJ, Soong S-J, editors. Cutaneous melanoma. 3rd ed. St Louis: Quality Med Pub; 1998. p. 55.Google Scholar
  2. 2.
    Bricca G, et al. Cutaneous head and neck melanoma treated with Mohs micrographic surgery. J Am Acad Dermatol. 2005;32(1):2099.CrossRefPubMedGoogle Scholar
  3. 3.
    Jahn H, Breuninger C, et al. Melanoma of the ear: prognostic factors and surgical strategies. Br J Dermatol. 2006;154(2):310–8.CrossRefPubMedGoogle Scholar
  4. 4.
    Byers RM, et al. Malignant melanoma of the external ear: review of 102 cases. Am J Surg. 1980;140:518.CrossRefPubMedGoogle Scholar
  5. 5.
    Rawlani R, Rawlani V, Qureshi HA, Kim JY, Wayne JD. Reducing margins of wide local excision in head and neck melanoma for function and cosmesis: 5-year local recurrence-free survival. J Surg Oncol. 2015;111(7):795–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Zenga J, Nussenbaum B, Cornelius LA, Linette GP, Desai SC. Management controversies in head and neck melanoma: a systematic review. JAMA Facial Plast Surg. 2017;19(1):53–62.CrossRefPubMedGoogle Scholar
  7. 7.
    Fata JJ. Composite chondrocutaneous advancement flap: a technique for the reconstruction of marginal defects of the ear. Plast Reconstr Surg. 1997;99:1172–5.CrossRefPubMedGoogle Scholar
  8. 8.
    Bialostocki A, Tan ST. Modified Antia-Buch repair for full thickness upper pole auricular defects. Plast Reconstr Surg. 1999;103:1476–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Thorne CH, Brecht LE, Bradley JP, Levine JP, Hammerschlag P, Longaker MT. Auricular reconstruction: indications for autogenous and prosthetic techniques. Plast Reconstr Surg. 2001;107:1241–12526.CrossRefPubMedGoogle Scholar
  10. 10.
    Brent B. The acquired auricular deformity: a systematic approach to its analysis and reconstruction. Plast Reconstr Surg. 1977;59:475–85.CrossRefPubMedGoogle Scholar
  11. 11.
    Brent B, Byrd HS. Secondary ear reconstruction with cartilage grafts covered by axial, random, and free flaps of temporoparietal fascia. Plast Reconstr Surg. 1983;72:141–52.CrossRefPubMedGoogle Scholar
  12. 12.
    Brent B, Upton J, Acland RD, Shaw WW, Finseth FJ, Rogers C, Pearl RM, Hentz VR. Experience with the temporoparietal fascial free flap. Plast Reconstr Surg. 1985;76:177–88.CrossRefPubMedGoogle Scholar
  13. 13.
    Nakai H. Reconstruction of microtia with a contouraccentuated framework and supplemental coverage. Plast Reconstr Surg. 1986;78:604–9.CrossRefPubMedGoogle Scholar
  14. 14.
    Rose EH, Norris MS. The versatile temporoparietal fascial flap: adaptability to a variety of composite defects. Plast Reconstr Surg. 1990;85:224–32.CrossRefPubMedGoogle Scholar
  15. 15.
    Tegtmeier RE, Gooding RA. The use of a fascial flap in ear reconstruction. Plast Reconstr Surg. 1977;60:406–11.PubMedGoogle Scholar
  16. 16.
    Park C, Lew D-H, Yoo W-M. An analysis of 123 temporoparietal fascial flaps: anatomic and clinical considerations in total auricular reconstruction. Plast Reconstr Surg. 1999;104:1295–306.CrossRefPubMedGoogle Scholar
  17. 17.
    Helling ER, Okoro S, Kim G II, Wang PT. Endoscope assisted temporoparietal fascia harvest for auricular reconstruction. Plast Reconstr Surg. 2008;121:1598–605.CrossRefPubMedGoogle Scholar
  18. 18.
    Nagata S. Secondary reconstruction for unfavorable microtia results utilizing temporoparietal and innominate fascia flaps. Plast Reconstr Surg. 1994;94:254–65.CrossRefPubMedGoogle Scholar
  19. 19.
    Brent B. Microtia repair with rib cartilage grafts: a review of personal experience with 1000 cases. Clin Plast Surg. 2002;29:257–71.CrossRefPubMedGoogle Scholar
  20. 20.
    Uppal RS, Sabbagh W, Chana J, Gault DT. Donor-site morbidity after autologous costal cartilage harvest in ear reconstruction and approaches to reducing donor-site contour deformity. Plast Reconstr Surg. 2008;121:1949–55.CrossRefPubMedGoogle Scholar
  21. 21.
    Thomson HG, Kim TY, Ein SH. Residual problems in chest donor sites after microtia reconstruction: a long-term study. Plast Reconstr Surg. 1995;95:961–8.CrossRefPubMedGoogle Scholar
  22. 22.
    Fukuda O, Yamada A. Reconstruction of the microticear with autogenous cartilage. Clin Plast Surg. 1978;5:351–66.PubMedGoogle Scholar
  23. 23.
    Kawanabe Y, Nagata S. A new method of costal cartilage harvest for total auricular reconstructionPart I. Avoidance and prevention of intraoperative and postoperative complications and problems. Plast Reconstr Surg. 2006;117:2011–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Ohmori S, Matsumoto K, Nakai H. Follow-up study on reconstruction of microtia with a silicone framework. Plast Reconstr Surg. 1974;53:555–62.CrossRefGoogle Scholar
  25. 25.
    Wellisz T. Clinical experience with the Medpor porous polyethylene implant. Aesthet Plast Surg. 1993;17:339–44.CrossRefGoogle Scholar
  26. 26.
    Reinisch J. Microtia reconstruction using a polyethylene implant: An 8-year surgical experience. Presented at the 78th Annual Meeting of the American Association of Plastic Surgeons, Colorado Springs, CO, May 5, 1999.Google Scholar
  27. 27.
    Romo T III, Reitzen SD. Aesthetic microtia reconstruction with Medpor. Facial Plast Surg. 2008;24:120–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Yang SL, Zheng JH, Ding Z, Liu QY, Mao GY, Ji YP. Combined fascial flap and expanded skin flap for enveloping Medpor framework in microtia reconstruction. Aesthet Plast Surg. 2008;33:518–22.CrossRefGoogle Scholar
  29. 29.
    Burget GC, Menick FJ. Subunit principle in nasal reconstruction. Plastic Reconstr Surg. 1985;76(2):239–47.CrossRefGoogle Scholar
  30. 30.
    Menick FJ. Artistry in facial surgery: aesthetic perceptions and the subunit principle. In: Furnas D, editor. Clinics in plastic surgery, vol. 14. Philadelphia: WB Saunders; 1987. p. 723.Google Scholar
  31. 31.
    Weathers WM, Bhadkamkar M, Wolfswinkel EM, Thornton JF. Full-thickness skin grafting in nasal reconstruction. Semin Plast Surg. 2013;27(2):90–5.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Marchac D, Toth B. The axial frontonasal flap revisited. Plast Reconstr Surg. 1985;76(5):686–94.CrossRefPubMedGoogle Scholar
  33. 33.
    McGregor JC, Soutar DS. A critical assessment of the bilobed flap. Br J Plast Surg. 1981;34(2):197–205.CrossRefPubMedGoogle Scholar
  34. 34.
    Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol. 1989;125(7):957–9.CrossRefPubMedGoogle Scholar
  35. 35.
    Burget GC, Menik FJ. Nasal reconstruction: seeking a fourth dimension. Plast Reconstr Surg. 1986;78(2):145–57.CrossRefPubMedGoogle Scholar
  36. 36.
    Menick FJ. The aesthetic use of the forehead for nasal reconstruction—the paramedian forehead flaps. In: Tobin G, editor. Clinics in plastic surgery. Philadelphia: WB Saunders; 1990. p. 607.Google Scholar
  37. 37.
    Menick FJ. Ten-year experience in nasal reconstruction with the three-stage forehead flap. Plast Reconstr Surg. 2002;109(6):1839–55.CrossRefPubMedGoogle Scholar
  38. 38.
    Maves M, Yessenow R. The use of composite auricular grafts in nasal reconstruction. J Dermatol Surg Oncol. 1988;114(9):994–9.CrossRefGoogle Scholar
  39. 39.
    Herbert DC. A subcutaneous pedicle cheek flap for reconstruction of ala defects. Br J Plast Surg. 1978;31(2):79–92.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Charles L. Dupin
    • 1
    Email author
  • Julian D’Achille
    • 1
  • Ian R. Wisecarver
    • 2
  1. 1.Division of Plastic and Reconstructive Surgery, Department of SurgeryLouisiana State University Health Sciences CenterNew OrleansUSA
  2. 2.Louisiana State University Health Sciences CenterNew OrleansUSA

Personalised recommendations