PullThrough Subcutaneous Pedicle Flap for an Anterior Auricular ...

RECONSTRUCTIVE CONUNDRUMPull-Through Subcutaneous Pedicle Flap for an AnteriorAuricular DefectDENNIS H. NGUYEN, MD, FAAD, AND JEREMY S. BORDEAUX, MD, MPH, FAAD The authors have indicated no significant interest with commercial supporters.A60-year-old man without significantprevious medical history underwent twostages of Mohs micrographic surgery for removalof a basal cell carcinoma of the right scaphoidfossa and superior antihelix. Tumor extirpationwas through the dermis and perichondrium,exposing bare and intact auricular cartilage.The resulting defect measured 18 20 mm(Figure 1). How would you reconstruct thisdefect?Figure 1. Mohs defect of the scaphoid fossa and superior antihelix measuring 18 20 mm. Both authors are affiliated with Department of Dermatology, Case Western Reserve University and University Hospitals,Cleveland, Ohio& 2010 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc. ISSN: 1076-0512 Dermatol Surg 2010;36:945–949 DOI: 10.1111/j.1524-4725.2010.01575.x945

PULL-THROUGH SUBCUTANEOUS PEDICLE FLAPResolutionExcision of cutaneous tumors of the ear and theirsubsequent repair are commonly encountered inMohs micrographic surgery. A defect of the anteriorauricle presents a unique reconstructive dilemma inwhich specific concerns need to be addressed: Is the perichondrium intact? Is the cartilage intact? Can function (supporting glasses and hearing aids)be maintained? Where can skin be recruited from for the repair?In reviewing the options for this anterior auriculardefect, one could advocate for ‘‘nonrepair.’’ Secondintentionhealing is ideal for smaller, shallow defectsof concave surfaces such as the scaphoid fossa,conchal bowl, temple, or nasion/medial canthus. Inthis case, there is little fear that contraction will altera free margin or significantly alter function, butbare cartilage is a suboptimal, avascular wound bedthat may need to be excised or perforated throughto the opposing perichondrium to better supportre-epithelialization. Healing time can be lengthy.A full-thickness skin graft is a remarkably hardyoption that can be employed for this defect. Hairlessareas of the preauricular cheek or photo-protectedareas of the postauricular scalp are suitable donorsites that can provide an acceptable color and texturematch. For thin-skinned areas such as the scaphoidfossa, a split-thickness skin graft can also be a viableoption. As in the case with second-intention healing,viability of the graft on bare cartilage may requireexcision or perforation of the cartilage to facilitateimbibition and inosculation from the opposing perichondrium.Significantly altering the cartilage toprepare for the graft may compromise the form andrigidity of the auricle. In addition, seroma andhematoma formation under the graft may compromiseits viability. To ensure a vascular wound bed,delayed grafting is also an option but requiressufficient time for granulation tissue to form.Some authors have proposed a staged interpolation,pull-through flap for this kind of anterior auriculardefect. 1–3 Using the postauricular scalp, a cutaneousflap is incised and pulled through a slit incision at thedistal portion of the anterior defect. The flap is insetand allowed to take before being divided in a secondprocedure. This random pattern flap probably derivesits vascular supply from tributaries of the posteriorauricular artery. Cosmetic outcome is usuallyexcellent.We propose that a postauricular scalp–to–anteriorauricle pull-through subcutaneous pedicle flapshould be considered for this defect of the scaphoidfossa and antihelix. Masson 4 first described this flap,which has been called the ‘‘revolving door’’ flap 5,6and the ‘‘flip-flop’’ flap, 7 in the plastic surgery literaturein 1972 to describe the general movement ofthe pedicled flap. It is a versatile reconstructive optionthat has been applied to defects of the scaphoidfossa, antihelix, and conchal bowl. The flap’s mainadvantages are that it can be used for large defectsand uses skin that is protected and well vascularized.Furthermore, it is performed as a one-stageprocedure.In executing this flap, the auricle is reflectedanteriorally, and an area of donor skin is measuredand marked just posterior to the postauricular sulcus(Figure 2). This flap is incised as an island thatFigure 2. Flap donor site marked.946DERMATOLOGIC SURGERY

NGUYEN AND BORDEAUXFigure 3. Slit excision through auricular cartilage.Figure 5. Flap set into the defect.maintains a subcutaneous pedicle that originatesfrom the postauricular sulcus. Reasonable hemostasisshould be obtained without compromising thevascular pedicle. Returning the auricle to its normalanatomical position, a slit excision at the proximalaspect of the defect is taken through the auricularcartilage and to the base of the flap’s pedicle in thepostauricular sulcus (Figure 3). The excision shouldbe sufficient to accommodate the pedicle withoutvascular compromise; it may be necessary to excise a1- to 2-mm strip of cartilage to accomplish this.The flap and its pedicle are pulled through theauricular excision (Figure 4) and laid atop the defect(Figure 5). Without tension, torsion, or impingementof the pedicle, the flap should be well perfused.The flap is inset with fine nonabsorbablesuperficial sutures (Figure 6), and the secondarydefect is easily closed primarily. A standard pressuredressing is applied, and the patient is instructedto protect the area from trauma. Envisioningthe pages of a book can be a helpful analogy invisualizing the movement and execution of thisrepair (Figure 7).In our patient, follow-up at 2 months revealed excellentaesthetic and functional results of the primary(Figure 8) and secondary (Figure 9) sites. Vascularsupply from tributaries of the posterior auricularartery contribute to the viability of this flap. 8Other authors have stated that neurologic function isFigure 4. The flap and pedicle before being pulled throughthe excision.Figure 6. Flap sutured into place.36:6:JUNE 2010 947

PULL-THROUGH SUBCUTANEOUS PEDICLE FLAPFigure 9. The secondary site at the 2-month follow-up visit.maintained, and indeed, our patient regainedminimal sensation at his flap site. 9 A potentialdrawback of this flap includes pullingback or ‘‘pinning’’ of the ear. Also, overmanipulationand incision of auricular cartilage may lead topain and chondritis. Pain, if prolonged, canbe a symptom of subclinical infection, and aprophylactic course of an appropriate antibiotic,particularly in patients with diabetes mellitus,may be considered.Figure 7. (A) The ear can be visualized as a leaflet between thepages of a book. With the defect on the anterior surface, a slitexcision is taken through the auricular cartilage. (B) The ear isreflected anteriorally, and the flap is taken from the postauricularscalp. The subcutaneous pedicle is based in the postauricularsulcus. (C) The flap and pedicle are pulled through theauricular excision, set into the defect, and sutured into place.A subcutaneous, pull-through island pedicle flap isan ideal and versatile reconstructive choice forlarge defects of the anterior auricle that involveperichondrium.References1. Johnson T, Fader D. The staged retroauricular to auricular directpedicle (interpolation) flap for helical ear reconstruction. J AmAcad Dermatol 1997;37:975–8.2. Mellette J. Reconstruction of the ear. In: Lask G, Moy R, editors.Principles and Techniques of Cutaneous Surgery. Los Angeles:McGraw-Hill; 1996. p. 369–74.3. Nguyen T. Staged cheek-to-nose and auricular interpolation flaps.Dermatol Surg 2005;31:1034–45.4. Masson J. A simple island flap for reconstruction of concha-helixdefects. Br J Plast Surg 1972;25:399–403.Figure 8. Two-month follow-up visit.5. Humphreys T, Goldberg L. The postauricular (revolvingdoor) island pedicle flap revisited. Dermatol Surg 1996;22:148–50.948DERMATOLOGIC SURGERY

NGUYEN AND BORDEAUX6. Politi M, Robiony M. Anthelix-conchal reconstruction with postauricular‘‘revolving door’’ island flap. Int J Oral Maxillofac Surg1995;24:340–1.7. Talmi Y, Horowitz Z, Bedrin L, Kronenberg J. Auricularreconstruction with a postauricular myocutaneous islandflap: flip-flop flap. Plast Reconstr Surg 1996;98:1191–9.8. Talmi Y, Liokumovitch P, Wolf M, et al. Anatomy of the postauricularisland ‘‘revolving door’’ flap (‘‘flip-flop’’ flap). Ann PlastSurg 1997;39:603–7.9. Turkaslan T, Kul Z, Isler C, Ozsoy Z. Reconstruction of theanterior surface of the ear using a postauricular pull-throughneurovascular island flap. Ann Plast Surg 2006;56:609–13.Address correspondence and reprint requests to: Dennis H.Nguyen, MD, Kaiser Permanente – Rancho CordovaMedical Officers, 10725 International Drive, 2nd Floor,Mohs Surgery, Rancho Cordova, CA 95670, ore-mail: dennguyen@gmail.com36:6:JUNE 2010 949