RECONSTRUCTIVE CONUNDRUM

Pull-Through Subcutaneous Pedicle Flap for an AnteriorAuricular Defect

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

The authors have indicated no significant interest with commercial supporters.

A 60-year-old man without significant

previous medical history underwent two

stages of Mohs micrographic surgery for removal

of a basal cell carcinoma of the right scaphoid

fossa and superior antihelix. Tumor extirpation

was through the dermis and perichondrium,

exposing bare and intact auricular cartilage.

The resulting defect measured 18�20 mm

(Figure 1). How would you reconstruct this

defect?

& 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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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 Hos-pitals, Cleveland, Ohio

Resolution

Excision of cutaneous tumors of the ear and their

subsequent repair are commonly encountered in

Mohs micrographic surgery. A defect of the anterior

auricle presents a unique reconstructive dilemma in

which 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 auricular

defect, one could advocate for ‘‘nonrepair.’’ Second-

intention healing is ideal for smaller, shallow defects

of concave surfaces such as the scaphoid fossa,

conchal bowl, temple, or nasion/medial canthus. In

this case, there is little fear that contraction will alter

a free margin or significantly alter function, but

bare cartilage is a suboptimal, avascular wound bed

that may need to be excised or perforated through

to the opposing perichondrium to better support

re-epithelialization. Healing time can be lengthy.

A full-thickness skin graft is a remarkably hardy

option that can be employed for this defect. Hairless

areas of the preauricular cheek or photo-protected

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.

Some authors have proposed a staged interpolation,

pull-through flap for this kind of anterior auricular

defect.1–3 Using the postauricular scalp, a cutaneous

flap is incised and pulled through a slit incision at the

distal portion of the anterior defect. The flap is inset

and allowed to take before being divided in a second

procedure. This random pattern flap probably de-

rives its vascular supply from tributaries of the pos-

terior auricular artery. Cosmetic outcome is usually

excellent.

We propose that a postauricular scalp–to–anterior

auricle pull-through subcutaneous pedicle flap

should be considered for this defect of the scaphoid

fossa and antihelix. Masson4 first described this flap,

which has been called the ‘‘revolving door’’ flap5,6

and the ‘‘flip-flop’’ flap,7 in the plastic surgery liter-

ature in 1972 to describe the general movement of

the pedicled flap. It is a versatile reconstructive op-

tion that has been applied to defects of the scaphoid

fossa, antihelix, and conchal bowl. The flap’s main

advantages are that it can be used for large defects

and uses skin that is protected and well vascularized.

Furthermore, it is performed as a one-stage

procedure.

In executing this flap, the auricle is reflected

anteriorally, and an area of donor skin is measured

and marked just posterior to the postauricular sulcus

(Figure 2). This flap is incised as an island that

Figure 2. Flap donor site marked.

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maintains a subcutaneous pedicle that originates

from the postauricular sulcus. Reasonable hemosta-

sis should be obtained without compromising the

vascular pedicle. Returning the auricle to its normal

anatomical position, a slit excision at the proximal

aspect of the defect is taken through the auricular

cartilage and to the base of the flap’s pedicle in the

postauricular sulcus (Figure 3). The excision should

be sufficient to accommodate the pedicle without

vascular compromise; it may be necessary to excise a

1- to 2-mm strip of cartilage to accomplish this.

The flap and its pedicle are pulled through the

auricular excision (Figure 4) and laid atop the defect

(Figure 5). Without tension, torsion, or impingement

of the pedicle, the flap should be well perfused.

The flap is inset with fine nonabsorbable

superficial sutures (Figure 6), and the secondary

defect is easily closed primarily. A standard pressure

dressing is applied, and the patient is instructed

to protect the area from trauma. Envisioning

the pages of a book can be a helpful analogy in

visualizing the movement and execution of this

repair (Figure 7).

In our patient, follow-up at 2 months revealed ex-

cellent aesthetic and functional results of the primary

(Figure 8) and secondary (Figure 9) sites. Vascular

supply from tributaries of the posterior auricular

artery contribute to the viability of this flap.8

Other authors have stated that neurologic function is

Figure 3. Slit excision through auricular cartilage.

Figure 4. The flap and pedicle before being pulled throughthe excision.

Figure 5. Flap set into the defect.

Figure 6. Flap sutured into place.

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maintained, and indeed, our patient regained

minimal sensation at his flap site.9 A potential

drawback of this flap includes pulling

back or ‘‘pinning’’ of the ear. Also, overmanipulation

and incision of auricular cartilage may lead to

pain and chondritis. Pain, if prolonged, can

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.

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

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

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 postauric-ular scalp. The subcutaneous pedicle is based in the postau-ricular sulcus. (C) The flap and pedicle are pulled through theauricular excision, set into the defect, and sutured into place.

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6. Politi M, Robiony M. Anthelix-conchal reconstruction with post-

auricular ‘‘revolving door’’ island flap. Int J Oral Maxillofac Surg

1995;24:340–1.

7. Talmi Y, Horowitz Z, Bedrin L, Kronenberg J. Auricular

reconstruction with a postauricular myocutaneous island

flap: flip-flop flap. Plast Reconstr Surg 1996;98:

1191–9.

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.

9. Turkaslan T, Kul Z, Isler C, Ozsoy Z. Reconstruction of the

anterior surface of the ear using a postauricular pull-through

neurovascular 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.com

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