PullThrough Subcutaneous Pedicle Flap for an Anterior Auricular ...
Transcript of PullThrough Subcutaneous Pedicle Flap for an Anterior Auricular ...
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: [email protected]
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