Pull-Through Subcutaneous Pedicle Flap for an Anterior ...

RECONSTRUCTIVE CONUNDRUM

Pull-Through Subcutaneous Pedicle Flap for an Anterior
Auricular Defect

DENNIS H. NGUYEN, MD, FAAD, AND JEREMY S. BORDEAUX, MD, MPH, FAADÃ

The authors have indicated no significant interest with commercial supporters.

A 60-year-old man without significant was through the dermis and perichondrium,
previous medical history underwent two exposing bare and intact auricular cartilage.
stages of Mohs micrographic surgery for removal The resulting defect measured 18 Â 20 mm
of a basal cell carcinoma of the right scaphoid (Figure 1). How would you reconstruct this
fossa and superior antihelix. Tumor extirpation defect?

Figure 1. Mohs defect of the scaphoid fossa and superior antihelix measuring 18 Â 20 mm.

ÃBoth authors are affiliated with Department of Dermatology, Case Western Reserve University and University Hos-
pitals, 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.x

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PULL-THROUGH SUBCUTANEOUS PEDICLE FLAP

Resolution Some authors have proposed a staged interpolation,
pull-through flap for this kind of anterior auricular
Excision of cutaneous tumors of the ear and their defect.1–3 Using the postauricular scalp, a cutaneous
subsequent repair are commonly encountered in flap is incised and pulled through a slit incision at the
Mohs micrographic surgery. A defect of the anterior distal portion of the anterior defect. The flap is inset
auricle presents a unique reconstructive dilemma in and allowed to take before being divided in a second
which specific concerns need to be addressed: procedure. This random pattern flap probably de-
rives its vascular supply from tributaries of the pos-
Is the perichondrium intact? terior auricular artery. Cosmetic outcome is usually
excellent.
Is the cartilage intact?

Can function (supporting glasses and hearing aids) We propose that a postauricular scalp–to–anterior
be maintained? auricle pull-through subcutaneous pedicle flap
should be considered for this defect of the scaphoid
Where can skin be recruited from for the repair? fossa and antihelix. Masson4 first described this flap,
which has been called the ‘‘revolving door’’ flap5,6
In reviewing the options for this anterior auricular and the ‘‘flip-flop’’ flap,7 in the plastic surgery liter-
defect, one could advocate for ‘‘nonrepair.’’ Second- ature in 1972 to describe the general movement of
intention healing is ideal for smaller, shallow defects the pedicled flap. It is a versatile reconstructive op-
of concave surfaces such as the scaphoid fossa, tion that has been applied to defects of the scaphoid
conchal bowl, temple, or nasion/medial canthus. In fossa, antihelix, and conchal bowl. The flap’s main
this case, there is little fear that contraction will alter advantages are that it can be used for large defects
a free margin or significantly alter function, but and uses skin that is protected and well vascularized.
bare cartilage is a suboptimal, avascular wound bed Furthermore, it is performed as a one-stage
that may need to be excised or perforated through procedure.
to the opposing perichondrium to better support In executing this flap, the auricle is reflected
re-epithelialization. Healing time can be lengthy. anteriorally, and an area of donor skin is measured
and marked just posterior to the postauricular sulcus
A full-thickness skin graft is a remarkably hardy (Figure 2). This flap is incised as an island that
option that can be employed for this defect. Hairless
areas of the preauricular cheek or photo-protected Figure 2. Flap donor site marked.
areas of the postauricular scalp are suitable donor
sites that can provide an acceptable color and texture
match. For thin-skinned areas such as the scaphoid
fossa, a split-thickness skin graft can also be a viable
option. As in the case with second-intention healing,
viability of the graft on bare cartilage may require
excision or perforation of the cartilage to facilitate
imbibition and inosculation from the opposing per-
ichondrium. Significantly altering the cartilage to
prepare for the graft may compromise the form and
rigidity of the auricle. In addition, seroma and
hematoma formation under the graft may compro-
mise its viability. To ensure a vascular wound bed,
delayed grafting is also an option but requires
sufficient time for granulation tissue to form.

946 DERMATOLOGIC SURGERY

NGUYEN AND BORDEAUX

Figure 3. Slit excision through auricular cartilage. Figure 5. Flap set into the defect.

maintains a subcutaneous pedicle that originates The flap is inset with fine nonabsorbable
from the postauricular sulcus. Reasonable hemosta- superficial sutures (Figure 6), and the secondary
sis should be obtained without compromising the defect is easily closed primarily. A standard pressure
vascular pedicle. Returning the auricle to its normal dressing is applied, and the patient is instructed
anatomical position, a slit excision at the proximal to protect the area from trauma. Envisioning
aspect of the defect is taken through the auricular the pages of a book can be a helpful analogy in
cartilage and to the base of the flap’s pedicle in the visualizing the movement and execution of this
postauricular sulcus (Figure 3). The excision should repair (Figure 7).
be sufficient to accommodate the pedicle without
vascular compromise; it may be necessary to excise a In our patient, follow-up at 2 months revealed ex-
1- to 2-mm strip of cartilage to accomplish this. cellent aesthetic and functional results of the primary
The flap and its pedicle are pulled through the (Figure 8) and secondary (Figure 9) sites. Vascular
auricular excision (Figure 4) and laid atop the defect supply from tributaries of the posterior auricular
(Figure 5). Without tension, torsion, or impingement artery contribute to the viability of this flap.8
of the pedicle, the flap should be well perfused. Other authors have stated that neurologic function is

Figure 4. The flap and pedicle before being pulled through

the excision. Figure 6. Flap sutured into place.

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PULL-THROUGH SUBCUTANEOUS PEDICLE FLAP

Figure 9. The secondary site at the 2-month follow-up visit.

Figure 7. (A) The ear can be visualized as a leaflet between the maintained, and indeed, our patient regained
pages of a book. With the defect on the anterior surface, a slit minimal sensation at his flap site.9 A potential
excision is taken through the auricular cartilage. (B) The ear is drawback of this flap includes pulling
reflected anteriorally, and the flap is taken from the postauric- back or ‘‘pinning’’ of the ear. Also, overmanipulation
ular scalp. The subcutaneous pedicle is based in the postau- and incision of auricular cartilage may lead to
ricular sulcus. (C) The flap and pedicle are pulled through the pain and chondritis. Pain, if prolonged, can
auricular excision, set into the defect, and sutured into place. be a symptom of subclinical infection, and a
prophylactic course of an appropriate antibiotic,
particularly in patients with diabetes mellitus,
may be considered.

A subcutaneous, pull-through island pedicle flap is
an ideal and versatile reconstructive choice for
large defects of the anterior auricle that involve
perichondrium.

Figure 8. Two-month follow-up visit. References

1. Johnson T, Fader D. The staged retroauricular to auricular direct
pedicle (interpolation) flap for helical ear reconstruction. J Am
Acad 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-helix
defects. Br J Plast Surg 1972;25:399–403.

5. Humphreys T, Goldberg L. The postauricular (revolving
door) island pedicle flap revisited. Dermatol Surg 1996;22:
148–50.

948 DERMATOLOGIC SURGERY

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6. Politi M, Robiony M. Anthelix-conchal reconstruction with post- 9. Turkaslan T, Kul Z, Isler C, Ozsoy Z. Reconstruction of the
auricular ‘‘revolving door’’ island flap. Int J Oral Maxillofac Surg anterior surface of the ear using a postauricular pull-through
1995;24:340–1. neurovascular island flap. Ann Plast Surg 2006;56:609–13.

7. Talmi Y, Horowitz Z, Bedrin L, Kronenberg J. Auricular Address correspondence and reprint requests to: Dennis H.
reconstruction with a postauricular myocutaneous island Nguyen, MD, Kaiser Permanente – Rancho Cordova
flap: flip-flop flap. Plast Reconstr Surg 1996;98: Medical Officers, 10725 International Drive, 2nd Floor,
1191–9. Mohs Surgery, Rancho Cordova, CA 95670, or
e-mail: [email protected]
8. Talmi Y, Liokumovitch P, Wolf M, et al. Anatomy of the postau-
ricular island ‘‘revolving door’’ flap (‘‘flip-flop’’ flap). Ann Plast
Surg 1997;39:603–7.

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