Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 68, e33ee34
CORRESPONDENCE AND COMMUNICATION A divided and sliding postauricular myocutaneous flap for anterior auricular reconstruction
based in the mastoid area. The pedicle width was set at about 5 cm before the fascial incision. After the flap elevation, the width was about 3 cm owing to the fascial shrinkage under natural tension. The skin paddle was
Dear Sir, Reconstruction of anterior auricular skin defects by use of postauricular subcutaneous flaps has been reported.1e3 Although these methods are excellent, they have disadvantages in terms of the donor site. When the flap is too large to permit direct closure of the donor site, a skin graft is required after the flap elevation. Although direct closure carries the risk of narrowing the auriculotemporal space, the final scar is more acceptable than that of a skin graft. Here, we present a case in which an anterior auricular skin defect was successfully reconstructed with a divided and sliding postauricular myocutaneous flap to permit direct closure of the donor site. A 23-year-old woman had bilateral ear deformities due to skin contractures. The contractures were caused by a viral infection acquired during the neonatal period, although the details of the infection were uncertain. The anterior auricular skin was tight and contracted such that it adhered between the helix and the concha. The auricular cartilage was deformed, and her ears fell forward (Figure 1). The right ear deformity was milder than the left. Before the reconstructive surgery, the patient hoped for less-invasive surgery and had two requests: that she would be able to return to work as soon as possible after the surgery and that there would be no other scar besides the one around the ears. Therefore, she rejected a skin graft because of the secondary skin defect it would entail. We planned a postauricular myocutaneous flap. The dividing and sliding technique was used for the left ear only. Therefore, we will report here only about the left ear. The operation was performed under general anesthesia. When we released the scar contracture, a 25 23 mm skin defect appeared. The auricular frame showed atrophy and deformity. A 50 12 mm skin paddle was designed around the mastoid area. When the postauricular myosubcutaneous flap was elevated, the flap pedicle was anteriorly
Figure 1 Preoperative image and design are shown. The anterior auricular skin was tight and contracted such that it adhered between the helix and the concha. After the release from the contracture, a skin paddle was designed around the mastoid area, so as not to include the hair. The flap pedicle was anteriorly based in the mastoid area. The skin paddle was divided into two. A subcutaneous tunnel through the conchal cartilage defect was made from the mastoid area to the anterior skin defect. The two sliding flaps were placed through the tunnel and over the skin defect.
http://dx.doi.org/10.1016/j.bjps.2014.09.039 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
e34 divided into two (Figure 1). These flaps were slid in and sutured together as one flap. Both conchal cartilage strips were craniocaudally harvested from the posterior incision. They were joined and fixed with nylon sutures to form the frame of the helix. A subcutaneous tunnel through the conchal cartilage defect was constructed from the mastoid area to the anterior skin defect. The flap was placed through the tunnel and over the skin defect. The donor site was closed primarily without any secondary complications. The postoperative course was uneventful. The patient returned to work seven days after the surgery. At the 12month postoperative follow-up, the appearance of the auricle was satisfactory, and the ears no longer fell anteriorly. The final scar of the donor site was concealed by her hairline. The patient was satisfied with the result and did not require additional revisional surgery (Figure 2). The postauricular flap has been used for ear reconstruction since it was first described by Masson in 1972.3 Its cosmetic result is superior to those of previously described reconstructive techniques.1,4 The closure of the donor site is usually direct. But when the defect is too large to permit direct closure, a skin graft must be performed, which entails complications associated with the secondary donor site, ie, scarring or a low-set auricle due to narrowing of the auriculotemporal space. A divided and sliding postauricular myocutaneous flap can improve such problems. Dividing a
Correspondence and communication flap to narrow its width permits direct closure. The flap can be used effectively, without the skin sagging produced by the sliding maneuver. These flap techniques have been reported for the latissimus dorsi flap.5 However, few reports have been published on auricular reconstruction using this method. We harvested the flap from the patient’s hairline in the mastoid region, which seems to be a suitable region for auricular reconstruction in terms of hiding the scar without narrowing the auriculotemporal space. The aim of this method is direct closure of the donor site; therefore, skin extensibility is important. In our case, a skin width of 12 mm under cicatricial tight skin tension caused by viral infection could be closed. For skin without cicatricial changes, direct closure of wounds of up to 20 mm in width may be possible. The maximum flap size that achieves a balance between the final scar and flap survival is unclear and requires further discussion. In conclusion, a divided and sliding postauricular myocutaneous flap can improve the problems associated with the secondary skin defects of auricular reconstructive surgery. This method is useful for achieving a balance between large flap size and donor site deformity.
Funding None.
Conflicts of interest None declared.
Ethical approval Not required.
References 1. Talmi YP, Horowitz Z, Bedrin L, Kronenberg J. Auricular reconstruction with a postauricular myocutaneous island flap: flip-flop flap. Plast Reconstr Surg 1996;98:1191e9. 2. Dessy LA, Figus A, Fioramonti P, Mazzocchi M, Scuderi N. Reconstruction of anterior auricular conchal defect after malignancy excision: revolving-door flap versus full-thickness skin graft. J Plast Reconstr Aesthet Surg 2010;63:746e52. 3. Masson JK. A simple island flap for reconstruction of conchahelix defects. Br J Plast Surg 1972;25:399e403. 4. Krespi YP, Ries WR, Shugar JM, Sisson GA. Auricular reconstruction with postauricular myocutaneous flap. Otolaryngol Head Neck Surg 1983;91:193e6. 5. Sawaizumi M, Maruyama Y. Sliding shape-designed latissimus dorsi flap. Ann Plast Surg 1997;38:41e5.
Figure 2 At 12 months postoperatively, the flap had healed well. The donor site was closed without any secondary complications. The final scar of the donor site was concealed along her hairline. Although the helix was mildly deformed, the appearance of the auricle was satisfactory.
Kaoru Sasaki Koji Adachi Yukiko Aihara Mitsuru Sekido Department of Plastic and Reconstructive Surgery, University of Tsukuba, Tsukuba, Ibaraki, Japan E-mail address: [email protected] 15 August 2014
CORRESPONDENCE AND COMMUNICATION A divided and sliding postauricular myocutaneous flap for anterior auricular reconstruction
based in the mastoid area. The pedicle width was set at about 5 cm before the fascial incision. After the flap elevation, the width was about 3 cm owing to the fascial shrinkage under natural tension. The skin paddle was
Dear Sir, Reconstruction of anterior auricular skin defects by use of postauricular subcutaneous flaps has been reported.1e3 Although these methods are excellent, they have disadvantages in terms of the donor site. When the flap is too large to permit direct closure of the donor site, a skin graft is required after the flap elevation. Although direct closure carries the risk of narrowing the auriculotemporal space, the final scar is more acceptable than that of a skin graft. Here, we present a case in which an anterior auricular skin defect was successfully reconstructed with a divided and sliding postauricular myocutaneous flap to permit direct closure of the donor site. A 23-year-old woman had bilateral ear deformities due to skin contractures. The contractures were caused by a viral infection acquired during the neonatal period, although the details of the infection were uncertain. The anterior auricular skin was tight and contracted such that it adhered between the helix and the concha. The auricular cartilage was deformed, and her ears fell forward (Figure 1). The right ear deformity was milder than the left. Before the reconstructive surgery, the patient hoped for less-invasive surgery and had two requests: that she would be able to return to work as soon as possible after the surgery and that there would be no other scar besides the one around the ears. Therefore, she rejected a skin graft because of the secondary skin defect it would entail. We planned a postauricular myocutaneous flap. The dividing and sliding technique was used for the left ear only. Therefore, we will report here only about the left ear. The operation was performed under general anesthesia. When we released the scar contracture, a 25 23 mm skin defect appeared. The auricular frame showed atrophy and deformity. A 50 12 mm skin paddle was designed around the mastoid area. When the postauricular myosubcutaneous flap was elevated, the flap pedicle was anteriorly
Figure 1 Preoperative image and design are shown. The anterior auricular skin was tight and contracted such that it adhered between the helix and the concha. After the release from the contracture, a skin paddle was designed around the mastoid area, so as not to include the hair. The flap pedicle was anteriorly based in the mastoid area. The skin paddle was divided into two. A subcutaneous tunnel through the conchal cartilage defect was made from the mastoid area to the anterior skin defect. The two sliding flaps were placed through the tunnel and over the skin defect.
http://dx.doi.org/10.1016/j.bjps.2014.09.039 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
e34 divided into two (Figure 1). These flaps were slid in and sutured together as one flap. Both conchal cartilage strips were craniocaudally harvested from the posterior incision. They were joined and fixed with nylon sutures to form the frame of the helix. A subcutaneous tunnel through the conchal cartilage defect was constructed from the mastoid area to the anterior skin defect. The flap was placed through the tunnel and over the skin defect. The donor site was closed primarily without any secondary complications. The postoperative course was uneventful. The patient returned to work seven days after the surgery. At the 12month postoperative follow-up, the appearance of the auricle was satisfactory, and the ears no longer fell anteriorly. The final scar of the donor site was concealed by her hairline. The patient was satisfied with the result and did not require additional revisional surgery (Figure 2). The postauricular flap has been used for ear reconstruction since it was first described by Masson in 1972.3 Its cosmetic result is superior to those of previously described reconstructive techniques.1,4 The closure of the donor site is usually direct. But when the defect is too large to permit direct closure, a skin graft must be performed, which entails complications associated with the secondary donor site, ie, scarring or a low-set auricle due to narrowing of the auriculotemporal space. A divided and sliding postauricular myocutaneous flap can improve such problems. Dividing a
Correspondence and communication flap to narrow its width permits direct closure. The flap can be used effectively, without the skin sagging produced by the sliding maneuver. These flap techniques have been reported for the latissimus dorsi flap.5 However, few reports have been published on auricular reconstruction using this method. We harvested the flap from the patient’s hairline in the mastoid region, which seems to be a suitable region for auricular reconstruction in terms of hiding the scar without narrowing the auriculotemporal space. The aim of this method is direct closure of the donor site; therefore, skin extensibility is important. In our case, a skin width of 12 mm under cicatricial tight skin tension caused by viral infection could be closed. For skin without cicatricial changes, direct closure of wounds of up to 20 mm in width may be possible. The maximum flap size that achieves a balance between the final scar and flap survival is unclear and requires further discussion. In conclusion, a divided and sliding postauricular myocutaneous flap can improve the problems associated with the secondary skin defects of auricular reconstructive surgery. This method is useful for achieving a balance between large flap size and donor site deformity.
Funding None.
Conflicts of interest None declared.
Ethical approval Not required.
References 1. Talmi YP, Horowitz Z, Bedrin L, Kronenberg J. Auricular reconstruction with a postauricular myocutaneous island flap: flip-flop flap. Plast Reconstr Surg 1996;98:1191e9. 2. Dessy LA, Figus A, Fioramonti P, Mazzocchi M, Scuderi N. Reconstruction of anterior auricular conchal defect after malignancy excision: revolving-door flap versus full-thickness skin graft. J Plast Reconstr Aesthet Surg 2010;63:746e52. 3. Masson JK. A simple island flap for reconstruction of conchahelix defects. Br J Plast Surg 1972;25:399e403. 4. Krespi YP, Ries WR, Shugar JM, Sisson GA. Auricular reconstruction with postauricular myocutaneous flap. Otolaryngol Head Neck Surg 1983;91:193e6. 5. Sawaizumi M, Maruyama Y. Sliding shape-designed latissimus dorsi flap. Ann Plast Surg 1997;38:41e5.
Figure 2 At 12 months postoperatively, the flap had healed well. The donor site was closed without any secondary complications. The final scar of the donor site was concealed along her hairline. Although the helix was mildly deformed, the appearance of the auricle was satisfactory.
Kaoru Sasaki Koji Adachi Yukiko Aihara Mitsuru Sekido Department of Plastic and Reconstructive Surgery, University of Tsukuba, Tsukuba, Ibaraki, Japan E-mail address: [email protected] 15 August 2014
