Fig. 230. Closure of Wound after ‘Radical’ Mastoid Operation. A is the point at which the Y-shaped meatal flap is sutured to the skin.
These flaps may be formed in several different ways. The following is the technique I adopt: A long, narrow, curved bistoury is passed down the auditory meatus so that it projects through the detached end of the fibrous portion, its point being directed backwards. The auricle is held well forward and the fibrous portion of the meatus cut through posteriorly, from within outwards, for a short distance (Fig. 228). The edge of the bistoury is then directed in a slanting direction upwards and outwards, and the incision continued as far as the cartilaginous portion of the meatus, care being taken not to cut into the concha. The bistoury is then withdrawn and reinserted at the point at which it was first made to turn upwards. It is now directed downwards and outwards and, in a similar manner, the incision is made in a slanting direction towards the inferior margin of the cartilaginous meatus. In carrying out these manipulations care must be taken that the outer portion of the bistoury does not injure the tragus or other portion of the auricle, a mistake which can easily occur. The fibrous portion of the meatus is thus divided by a Y-shaped incision into three small flaps; namely, a posterior or external V-shaped flap, and a superior and an inferior flap (Fig. 229).
The outer flap is fixed to the skin behind the auricle by means of a catgut suture (Fig. 230), and the auricle is then pulled back into its normal position. By inserting the tip of a finger into the meatus, the upper and lower flaps are pressed upwards and downwards against the roof and floor of the mastoid cavity, and can be kept in position afterwards by suturing the flaps to the subcutaneous tissue or by packing the cavity through the meatus with a strip of ribbon gauze.
Amongst other methods the following may be mentioned:—
Körner’s method (Fig. 231). Two parallel incisions are made in a longitudinal direction through the fibrous portion of the posterior wall of the meatus and are prolonged outwards as far as the concha. On the auricle being restored to its normal position, this posterior flap is pressed backwards and so covers a large area of the posterior wound surface. The chief objection to it is that, owing to involvement of the concha, there is considerable enlargement of the meatal opening and therefore subsequent disfigurement.
Fig. 231. Körner’s Post-meatal Flap.
Panse’s method (Fig. 232). A transverse incision is carried through the posterior margin of the meatus, at the junction of the concha and auditory canal posteriorly. With a pair of scissors or knife, the posterior wall of the fibrous portion of the canal is now split by a longitudinal incision. In this way two flaps are formed, a superior and inferior one. They are fixed into position by catgut sutures through the subcutaneous tissues at the upper and lower angles of the wound.
Fig. 232. Panse’s Post-meatal Flap.