LETTERS AND COMMUNICATIONS
4. Alam M, Goldberg LH. Utility of fully buried horizontal mattress sutures. J Am Acad Dermatol 2004;50:73–6.
Timothy Wang, MD Cutaneous Surgery & Oncology Unit Johns Hopkins University Baltimore, Maryland
5. Hanasono MM, Hotchkiss RN. Locking horizontal mattress suture. Dermatol Surg 2005;31:572–3.
Catherine H. Lee, MD, MSc Newport Dermatology Institute Corona Del Mar, California
The authors have indicated no significant interest with commercial supporters.
Transposition–Advancement Flap for the Reconstruction of Segmental Auricular Defects Here, the authors present the utility of the transposition–advancement flap (TAF) for the single-stage repair of segmental auricular defects. Surgical Technique Example 1 Figure 1 illustrates a complex full-thickness 4 · 3 cm Mohs defect of the left ear. A triangular-shaped transposition flap (TF) is designed in the retroauricular sulcus with the apex of the triangle oriented inferiorly toward the side of the neck designed to align into a preexisting rhytid. The dimensions of the flap must be such that once elevated and transposed 90, the flap is both long enough and wide enough to be “folded” over itself to provide adequate skin coverage for both the posterior and anterior aspects of the ear, that is, the proximal half of the TF resurfaces the posterior aspect of the ear and the distal half the anterior ear. The size of the required TF for such a large defect is significant, and thus, a primary closure of the created secondary defect in the retroauricular sulcus is often not possible. Consequently, linking the TF to a curved advancement limb (CAL), at least 3· the width of the secondary defect, laterally along the parietooccipital scalp not only enables greater tension free movement of the TF itself but also allows direct primary closure of the created secondary defect. The curved nature of this advancement limb (as opposed to a straight limb) enables a greater recruitment of the lax tissue of the occipitoparietal scalp. The degree of curvature adopted may be modified according to each patient’s individual tissue laxity in this region.
The defect shown in Figure 1 was extended to involve the helical rim. An antihelical cartilage stent was then harvested from the contralateral ear and sutured in place to recreate the structural framework of the midhelical rim and maintain the height of the ear. The TAF is dissected extensively in a subcutaneous plane. The key primary stitch, a buried vertical mattress suture, approximates the leading edge of the CAL to the retroauricular sulcus. This movement closes the secondary defect created by the transposition limb and also facilitates the movement of the TF itself. The proximal aspect of the TF is then sutured to resurface the posterior aspect of the ear with the distal aspect of the TF being “wrapped round” the cartilage baton providing coverage for the anterior aspect of the ear, with the tip of the TF lying within the conchal bowl. Great care is taken to ensure the flap is “draped” without tension across the cartilage baton. The CAL within the occipital scalp is then sutured according to the “rule of halves.” Example 2 Figure 2 illustrates a Mohs defect, at the junction of the upper and middle third of the ear, approximately 1 cm wide and 4 cm in length. A small remnant remained at the superior crus of the helix. In this case, the TAF was performed in conjunction with a helical rim advancement flap. The TF limb of the flap in this case was initiated from the most inferoposterior aspect of the surgical defect (the midpoint of the retroauricular sulcus in this case) and elongated to the ipsilateral angle of the jaw to ensure enough length to allow this limb to be “draped” in a vertical fashion (rather than horizontally as in Figure
41:8:AUGUST 2015
977
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Figure 1. (A) A 4 · 3 cm full-thickness surgical defect of the left ear. (B) After removal of the thin strip of residual helical rim skin, a cartilage baton harvested from the contralateral antihelix is placed to provide structural support to the outer ear. The TF limb of the TAF is incised in the postauricular sulcus and elevated in a subcutaneous plane as shown. (Note the dotted area of this TF limb, which when transposed 90 provides coverage for the anterior aspect of the ear). (C) The flap is dissected widely in a subcutaneous plane. (D) Initially, the secondary defect is approximated, which then enables the base of the TF limb to provide skin coverage for the posterior ear. The dotted distal aspect of the TF then wraps itself around the helical rim to cover the anterior ear. (E) Lateral view at 3-month follow-up. (F) Posterior view at 3-month follow-up.
1) over a cartilage baton, thus again providing coverage for the posterior and anterior aspects of the ear. Example 3 Figure 3 illustrates a Mohs defect of the left helical rim. The defect involved loss of cartilage and subcutis of the majority of the midhelical rim. To reduce the size of the defect, superior and inferior helical rim advancement
978
flaps were performed. An antihelical cartilage baton was then harvested from the right ear and sutured in place to provide structural integrity to the left helical rim. A TAF was then incised and elevated in the manner described in Example 1, with the key principle once again involving the “horizontal draping” of the TF limb of the flap “without tension” to resurface both the anterior and posterior aspects of the ear. In this case, as the majority of the posterior ear surface was not involved, to allow the
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Figure 2. (A) A challenging surgical defect involving the superior third of the right ear. (B) The TAF here has been performed in conjunction with a helical rim advancement flap, thus narrowing the required width of the TF limb. In contrast to Figure 1D, in this case, the TF limb is draped vertically over the ear. (C) At 3-month review.
TF limb to be inset into the postauricular skin, the unaffected skin over which the TF was lying was deepithelialized. In this particular case, the CAL was also curved superiorly toward the parietal scalp to take advantage of the local tissue laxity in this patient’s scalp.
Discussion Although a variety of techniques have been described for partial thickness defects or small to medium fullthickness helical rim defects,1–4 the use of single-stage local flaps for larger and deeper defects of the ear is limited by the relative lack of a highly mobile tissue reservoir of either the preauricular or postauricular skin. Under such circumstances, a complex interpolated flap may be required. If sufficient surrounding cartilage support remains intact, wounds may be left to heal secondarily, although an extremely poor aesthetic outcome may result (Figure 4).
Despite its conception over 30 years ago,5 the utility of the TAF has not been widely propagated within the reconstructive literature. The linking of a postauricular TF to a large CAL within the occipital scalp in the TAF overcomes the relative lack of mobile tissue and enables a reliable single-stage repair for large auricular defects to take place. Not only are the flap’s incision lines well hidden in the retroauricular sulcus and parietooccipital scalp but also enables the height and width of the ear to be maintained, thereby overcoming the obvious discrepancy in the size of the 2 ears that occurs in a wedge resection of the midhelix. The authors have found that even in partial thickness auricular defects, because of the TF base effectively hidden within the retroauricular sulcus, there is often no need for revision or division as the flap does not bridge the retroauricular sulcus but follows its
Figure 3. (A) A longitudinal surgical defect resulting in loss of the middle third of the left helical rim. (B) Immediately at closure after repair with a TAF. (C) At 3-month review (lateral view). (D) Posterior view at 3-month follow-up. As the base of the TF limb is well hidden in the retroauricular sulcus, the patient declined further surgical intervention.
41:8:AUGUST 2015
979
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Figure 4. (A and B) Although the functional aspect of the auricle is preserved in both these cases (performed at separate different institutions), the aesthetic appearance is extremely poor.
contours. Indeed, the majority of the patients have actively declined a second stage for flap division when it has been offered. Acknowledgments The authors wish to acknowledge and express their gratitude to the patients from the Skin Cancer Institute, New Zealand, who allowed us to use the images shown in Figures 1–3. References 1. Harrington AC, Grande DJ, Sollitto RB. The chondrocutaneous helical rim advancement flap of Antia and Buch. Dermatol Surg 1996;22:892–3. 2. Goldberg LH, Mauldin DV, Humphreys TR. The postauricular cutaneous advancement flap for repairing ear rim defects. Dermatol Surg 1996;22:28–31. 3. Talmi YP, Horowitz Z, Bedrin L, Kronenberg J. Auricular reconstruction with a postauricular myocutaneous island flap: flip-flop flap. Plast Reconstr Surg 1996;98:1191–9. 4. Dagregorio G, Darsonval V. Peninsular conchal axial flap to reconstruct the upper or middle third of the auricle. Dermatol Surg 2005;31:350–5.
5. Weerda H, Münker G. The “transposition-rotation flap” in the one stage reconstruction of auricle defects [in German]. Laryngol Rhinol Otol (Stuttg) 1981;60:312–7.
Walayat Hussain, BSc (Hons), MBChB, MRCP (UK), FRACP, FACMS Department of Mohs Micrographic Surgery Dermatology Surgical and Laser Unit (C4) Leeds Centre for Dermatology Chapel Allerton Hospital Leeds, United Kingdom Paul Salmon, BhB, MBChB, FRACP, FACMS Dermatologic Surgical Unit Skin Cancer Institute Tauranga, New Zealand
The authors have indicated no significant interest with commercial supporters.
Intraoperative Real-Time Reflectance Confocal Microscopy for Guiding Surgical Margins of Lentigo Maligna Melanoma Lentigo maligna melanoma (LMM) represents a diagnostic and therapeutic challenge because of its heterogeneous nature with poorly defined borders, subclinical
980
extension, and location on sun-damaged skin. Reflectance confocal microscopy (RCM) has advanced the authors’ ability to better diagnose and manage these
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
4. Alam M, Goldberg LH. Utility of fully buried horizontal mattress sutures. J Am Acad Dermatol 2004;50:73–6.
Timothy Wang, MD Cutaneous Surgery & Oncology Unit Johns Hopkins University Baltimore, Maryland
5. Hanasono MM, Hotchkiss RN. Locking horizontal mattress suture. Dermatol Surg 2005;31:572–3.
Catherine H. Lee, MD, MSc Newport Dermatology Institute Corona Del Mar, California
The authors have indicated no significant interest with commercial supporters.
Transposition–Advancement Flap for the Reconstruction of Segmental Auricular Defects Here, the authors present the utility of the transposition–advancement flap (TAF) for the single-stage repair of segmental auricular defects. Surgical Technique Example 1 Figure 1 illustrates a complex full-thickness 4 · 3 cm Mohs defect of the left ear. A triangular-shaped transposition flap (TF) is designed in the retroauricular sulcus with the apex of the triangle oriented inferiorly toward the side of the neck designed to align into a preexisting rhytid. The dimensions of the flap must be such that once elevated and transposed 90, the flap is both long enough and wide enough to be “folded” over itself to provide adequate skin coverage for both the posterior and anterior aspects of the ear, that is, the proximal half of the TF resurfaces the posterior aspect of the ear and the distal half the anterior ear. The size of the required TF for such a large defect is significant, and thus, a primary closure of the created secondary defect in the retroauricular sulcus is often not possible. Consequently, linking the TF to a curved advancement limb (CAL), at least 3· the width of the secondary defect, laterally along the parietooccipital scalp not only enables greater tension free movement of the TF itself but also allows direct primary closure of the created secondary defect. The curved nature of this advancement limb (as opposed to a straight limb) enables a greater recruitment of the lax tissue of the occipitoparietal scalp. The degree of curvature adopted may be modified according to each patient’s individual tissue laxity in this region.
The defect shown in Figure 1 was extended to involve the helical rim. An antihelical cartilage stent was then harvested from the contralateral ear and sutured in place to recreate the structural framework of the midhelical rim and maintain the height of the ear. The TAF is dissected extensively in a subcutaneous plane. The key primary stitch, a buried vertical mattress suture, approximates the leading edge of the CAL to the retroauricular sulcus. This movement closes the secondary defect created by the transposition limb and also facilitates the movement of the TF itself. The proximal aspect of the TF is then sutured to resurface the posterior aspect of the ear with the distal aspect of the TF being “wrapped round” the cartilage baton providing coverage for the anterior aspect of the ear, with the tip of the TF lying within the conchal bowl. Great care is taken to ensure the flap is “draped” without tension across the cartilage baton. The CAL within the occipital scalp is then sutured according to the “rule of halves.” Example 2 Figure 2 illustrates a Mohs defect, at the junction of the upper and middle third of the ear, approximately 1 cm wide and 4 cm in length. A small remnant remained at the superior crus of the helix. In this case, the TAF was performed in conjunction with a helical rim advancement flap. The TF limb of the flap in this case was initiated from the most inferoposterior aspect of the surgical defect (the midpoint of the retroauricular sulcus in this case) and elongated to the ipsilateral angle of the jaw to ensure enough length to allow this limb to be “draped” in a vertical fashion (rather than horizontally as in Figure
41:8:AUGUST 2015
977
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Figure 1. (A) A 4 · 3 cm full-thickness surgical defect of the left ear. (B) After removal of the thin strip of residual helical rim skin, a cartilage baton harvested from the contralateral antihelix is placed to provide structural support to the outer ear. The TF limb of the TAF is incised in the postauricular sulcus and elevated in a subcutaneous plane as shown. (Note the dotted area of this TF limb, which when transposed 90 provides coverage for the anterior aspect of the ear). (C) The flap is dissected widely in a subcutaneous plane. (D) Initially, the secondary defect is approximated, which then enables the base of the TF limb to provide skin coverage for the posterior ear. The dotted distal aspect of the TF then wraps itself around the helical rim to cover the anterior ear. (E) Lateral view at 3-month follow-up. (F) Posterior view at 3-month follow-up.
1) over a cartilage baton, thus again providing coverage for the posterior and anterior aspects of the ear. Example 3 Figure 3 illustrates a Mohs defect of the left helical rim. The defect involved loss of cartilage and subcutis of the majority of the midhelical rim. To reduce the size of the defect, superior and inferior helical rim advancement
978
flaps were performed. An antihelical cartilage baton was then harvested from the right ear and sutured in place to provide structural integrity to the left helical rim. A TAF was then incised and elevated in the manner described in Example 1, with the key principle once again involving the “horizontal draping” of the TF limb of the flap “without tension” to resurface both the anterior and posterior aspects of the ear. In this case, as the majority of the posterior ear surface was not involved, to allow the
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Figure 2. (A) A challenging surgical defect involving the superior third of the right ear. (B) The TAF here has been performed in conjunction with a helical rim advancement flap, thus narrowing the required width of the TF limb. In contrast to Figure 1D, in this case, the TF limb is draped vertically over the ear. (C) At 3-month review.
TF limb to be inset into the postauricular skin, the unaffected skin over which the TF was lying was deepithelialized. In this particular case, the CAL was also curved superiorly toward the parietal scalp to take advantage of the local tissue laxity in this patient’s scalp.
Discussion Although a variety of techniques have been described for partial thickness defects or small to medium fullthickness helical rim defects,1–4 the use of single-stage local flaps for larger and deeper defects of the ear is limited by the relative lack of a highly mobile tissue reservoir of either the preauricular or postauricular skin. Under such circumstances, a complex interpolated flap may be required. If sufficient surrounding cartilage support remains intact, wounds may be left to heal secondarily, although an extremely poor aesthetic outcome may result (Figure 4).
Despite its conception over 30 years ago,5 the utility of the TAF has not been widely propagated within the reconstructive literature. The linking of a postauricular TF to a large CAL within the occipital scalp in the TAF overcomes the relative lack of mobile tissue and enables a reliable single-stage repair for large auricular defects to take place. Not only are the flap’s incision lines well hidden in the retroauricular sulcus and parietooccipital scalp but also enables the height and width of the ear to be maintained, thereby overcoming the obvious discrepancy in the size of the 2 ears that occurs in a wedge resection of the midhelix. The authors have found that even in partial thickness auricular defects, because of the TF base effectively hidden within the retroauricular sulcus, there is often no need for revision or division as the flap does not bridge the retroauricular sulcus but follows its
Figure 3. (A) A longitudinal surgical defect resulting in loss of the middle third of the left helical rim. (B) Immediately at closure after repair with a TAF. (C) At 3-month review (lateral view). (D) Posterior view at 3-month follow-up. As the base of the TF limb is well hidden in the retroauricular sulcus, the patient declined further surgical intervention.
41:8:AUGUST 2015
979
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Figure 4. (A and B) Although the functional aspect of the auricle is preserved in both these cases (performed at separate different institutions), the aesthetic appearance is extremely poor.
contours. Indeed, the majority of the patients have actively declined a second stage for flap division when it has been offered. Acknowledgments The authors wish to acknowledge and express their gratitude to the patients from the Skin Cancer Institute, New Zealand, who allowed us to use the images shown in Figures 1–3. References 1. Harrington AC, Grande DJ, Sollitto RB. The chondrocutaneous helical rim advancement flap of Antia and Buch. Dermatol Surg 1996;22:892–3. 2. Goldberg LH, Mauldin DV, Humphreys TR. The postauricular cutaneous advancement flap for repairing ear rim defects. Dermatol Surg 1996;22:28–31. 3. Talmi YP, Horowitz Z, Bedrin L, Kronenberg J. Auricular reconstruction with a postauricular myocutaneous island flap: flip-flop flap. Plast Reconstr Surg 1996;98:1191–9. 4. Dagregorio G, Darsonval V. Peninsular conchal axial flap to reconstruct the upper or middle third of the auricle. Dermatol Surg 2005;31:350–5.
5. Weerda H, Münker G. The “transposition-rotation flap” in the one stage reconstruction of auricle defects [in German]. Laryngol Rhinol Otol (Stuttg) 1981;60:312–7.
Walayat Hussain, BSc (Hons), MBChB, MRCP (UK), FRACP, FACMS Department of Mohs Micrographic Surgery Dermatology Surgical and Laser Unit (C4) Leeds Centre for Dermatology Chapel Allerton Hospital Leeds, United Kingdom Paul Salmon, BhB, MBChB, FRACP, FACMS Dermatologic Surgical Unit Skin Cancer Institute Tauranga, New Zealand
The authors have indicated no significant interest with commercial supporters.
Intraoperative Real-Time Reflectance Confocal Microscopy for Guiding Surgical Margins of Lentigo Maligna Melanoma Lentigo maligna melanoma (LMM) represents a diagnostic and therapeutic challenge because of its heterogeneous nature with poorly defined borders, subclinical
980
extension, and location on sun-damaged skin. Reflectance confocal microscopy (RCM) has advanced the authors’ ability to better diagnose and manage these
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
