RECONSTRUCTIVE CONUNDRUM
Transposition Pedicle Flap of the Posterior Ear Diane Trieu, MD, Anna Drosou, MD, and Leonard H. Goldberg, MD*
The authors have indicated no significant interest with commercial supporters.
measured 3.5 · 4.0 cm, involving full thickness of the epidermis and dermis with exposure of the perichondrium. How would you reconstruct this defect (Figure 1)?
A
n 80-year-old man was treated for a sclerotic basal cell carcinoma on his left posterior ear. The lesion was removed after 2 stages of Mohs surgery. The final defect was oval and
Figure 1. Defect after Mohs surgery.
*All the authors are affiliated with the Department of Dermatology, DermSurgery Associates, Houston Methodist, Houston, Texas
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© 2014 by the American Society for Dermatologic Surgery, Inc. Published by Lippincott Williams & Wilkins ISSN: 1076-0512 Dermatol Surg 2015;41:155–157 DOI: 10.1097/DSS.0000000000000192
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· 155
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
TRANSPOSITION PEDICLE FLAP
Figure 2. (A) Incising down to subcutaneous fat. Asterisk represents pivoting point and base of the pedicle. (B) Circular dot shows the subcutaneous pedicle. Arrow shows the key stitch.
Resolution Defects of the posterior ear are reconstructed for the primary objective of closure. Anatomically, the posterior ear is composed of epidermis and thin dermis with little to no subcutaneous fat overlying the cartilage of the ear. The skin of the posterior ear is bound down with little to no laxity. Posterior ear defects can be managed with numerous approaches depending on the size, depth, and location. Defects may be allowed to heal by second intention or closed with primary closure, split, or full-thickness skin grafts, O-to-T flaps, bilobed flaps, and rotation flaps.1–4 The reconstructive challenge in this defect was the large size and inelastic tissue of the superior posterior ear. Because the defect appeared to encompass over half of the posterior ear, second intention was not considered, as this would result in ear contracture and distortion. Although split and fullthickness skin grafts do relatively well on the ear, our defect had a large amount of cartilage exposed. A skin graft would have been susceptible to necrosis because of an insufficient vascular bed. The O-to-T flap and primary closures were not options because of a lack of tissue. A rotation flap was considered, but this would have required excessive undermining and difficulty in obtaining tissue over the mastoid bone. To solve our reconstructive challenge, we designed a transposition pedicle flap using loose skin from the neck at the posterior inferior aspect of the ear. First, the
156
flap was measured to approximately the same size of the defect and marked. Then, the marked edges were incised down to the subcutaneous fat (Figure 2A). Starting from the inferior edge, the flap was carefully dissected in the subcutaneous fat plane and stopped at the superior edge, leaving a subcutaneous pedicle at the pivoting edge of the flap where the epidermis remained intact (Figure 2A). The skin was rotated and transposed 180 on its pedicle located between the mastoid and the posterior aspect of the mandible. A key stitch was placed at the superior tip of the transposed tissue to the superior rim of the defect (Figure 2B). The transposed tissue was sutured in place with 5.0 nylon. The secondary defect
Figure 3. Final closure.
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
TRIEU ET AL
a reservoir for a transposition flap. Our transposition flap was designed with a subcutaneous pedicle at the superior aspect of the flap, with a blood supply based on the posterior auricular artery, from the posterior aspect of the parotid gland. A simple transposition flap in our case would have had a narrow base with an insufficient blood supply to support the flap. With a skin-based pedicle, the 180 rotation would have constricted the blood supply, resulting in necrosis of the flap. Thus, using blood supply based on a subcutaneous island, pedicle would ensure a greater chance of survival. In summary, we believe that this reconstruction should be considered as an alternative for large defects of the posterior ear. The patient had a great cosmetic result without any complications and only required a single-stage surgery. Conundrum Keys
Figure 4. Five-month postoperatively.
was then closed with 4.0 Monocryl and 5.0 nylon on a P-3 needle (Figure 3). Sutures were removed 2 weeks postoperatively. At the 2-week suture removal follow-up, the patient healed excellently. There were no postoperative complications with flap necrosis or dehiscence. No further postoperative revisions were required. The patient and physician were both pleased about the results. The final result at 5 months postoperatively is depicted below in Figure 4. Reconstruction of large defects on the posterior ear is challenging. There is minimal to no reservoir of excess skin for movement to close a defect, and the poor laxity of the skin does not provide a reservoir of adjacent skin for closure. However, the skin on the neck immediately inferior to the ear does provide
(1) Laxity of the posterior neck provides tissue reservoir for transposition flaps. (2) Advantages of using this flap include the ability to close a large defect, a 1-stage procedure, and good tissue color match. (3) Using a subcutaneous pedicle based on the blood supply of the posterior auricular artery ensures greater chance of flap survival.
References 1. Vergilis-Kalner IJ, Goldberg LH. Bilobed flap for reconstruction of defects of the helical rim and posterior ear. Dermatol Online J 2010; 16:9. 2. Brodland D. Auricular reconstruction. Dermatol Clin 2005;23:23–41. 3. Smith JB, Desciak EB, Eliezri YD. Repair of the posterior ear after Mohs micrographic surgery. Dermatol Surg 2002;28:1073–5. 4. Gladstone HB, Morganroth GS. Ear reconstruction. In: Rohrer TE, Cook JL, Nguyen TH, Mellete JM, editors. Flaps and grafts in dermatologic surgery. China: Elsevier; 2007; pp. 179–90.
Address correspondence and reprint requests to: Diane Trieu, MD, DermSurgery Associates, 7515 Main Street, Suite 240, Houston, TX 77030, or e-mail: [email protected]
41:1:JANUARY 2015
157
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
Transposition Pedicle Flap of the Posterior Ear Diane Trieu, MD, Anna Drosou, MD, and Leonard H. Goldberg, MD*
The authors have indicated no significant interest with commercial supporters.
measured 3.5 · 4.0 cm, involving full thickness of the epidermis and dermis with exposure of the perichondrium. How would you reconstruct this defect (Figure 1)?
A
n 80-year-old man was treated for a sclerotic basal cell carcinoma on his left posterior ear. The lesion was removed after 2 stages of Mohs surgery. The final defect was oval and
Figure 1. Defect after Mohs surgery.
*All the authors are affiliated with the Department of Dermatology, DermSurgery Associates, Houston Methodist, Houston, Texas
·
© 2014 by the American Society for Dermatologic Surgery, Inc. Published by Lippincott Williams & Wilkins ISSN: 1076-0512 Dermatol Surg 2015;41:155–157 DOI: 10.1097/DSS.0000000000000192
·
·
· 155
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
TRANSPOSITION PEDICLE FLAP
Figure 2. (A) Incising down to subcutaneous fat. Asterisk represents pivoting point and base of the pedicle. (B) Circular dot shows the subcutaneous pedicle. Arrow shows the key stitch.
Resolution Defects of the posterior ear are reconstructed for the primary objective of closure. Anatomically, the posterior ear is composed of epidermis and thin dermis with little to no subcutaneous fat overlying the cartilage of the ear. The skin of the posterior ear is bound down with little to no laxity. Posterior ear defects can be managed with numerous approaches depending on the size, depth, and location. Defects may be allowed to heal by second intention or closed with primary closure, split, or full-thickness skin grafts, O-to-T flaps, bilobed flaps, and rotation flaps.1–4 The reconstructive challenge in this defect was the large size and inelastic tissue of the superior posterior ear. Because the defect appeared to encompass over half of the posterior ear, second intention was not considered, as this would result in ear contracture and distortion. Although split and fullthickness skin grafts do relatively well on the ear, our defect had a large amount of cartilage exposed. A skin graft would have been susceptible to necrosis because of an insufficient vascular bed. The O-to-T flap and primary closures were not options because of a lack of tissue. A rotation flap was considered, but this would have required excessive undermining and difficulty in obtaining tissue over the mastoid bone. To solve our reconstructive challenge, we designed a transposition pedicle flap using loose skin from the neck at the posterior inferior aspect of the ear. First, the
156
flap was measured to approximately the same size of the defect and marked. Then, the marked edges were incised down to the subcutaneous fat (Figure 2A). Starting from the inferior edge, the flap was carefully dissected in the subcutaneous fat plane and stopped at the superior edge, leaving a subcutaneous pedicle at the pivoting edge of the flap where the epidermis remained intact (Figure 2A). The skin was rotated and transposed 180 on its pedicle located between the mastoid and the posterior aspect of the mandible. A key stitch was placed at the superior tip of the transposed tissue to the superior rim of the defect (Figure 2B). The transposed tissue was sutured in place with 5.0 nylon. The secondary defect
Figure 3. Final closure.
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
TRIEU ET AL
a reservoir for a transposition flap. Our transposition flap was designed with a subcutaneous pedicle at the superior aspect of the flap, with a blood supply based on the posterior auricular artery, from the posterior aspect of the parotid gland. A simple transposition flap in our case would have had a narrow base with an insufficient blood supply to support the flap. With a skin-based pedicle, the 180 rotation would have constricted the blood supply, resulting in necrosis of the flap. Thus, using blood supply based on a subcutaneous island, pedicle would ensure a greater chance of survival. In summary, we believe that this reconstruction should be considered as an alternative for large defects of the posterior ear. The patient had a great cosmetic result without any complications and only required a single-stage surgery. Conundrum Keys
Figure 4. Five-month postoperatively.
was then closed with 4.0 Monocryl and 5.0 nylon on a P-3 needle (Figure 3). Sutures were removed 2 weeks postoperatively. At the 2-week suture removal follow-up, the patient healed excellently. There were no postoperative complications with flap necrosis or dehiscence. No further postoperative revisions were required. The patient and physician were both pleased about the results. The final result at 5 months postoperatively is depicted below in Figure 4. Reconstruction of large defects on the posterior ear is challenging. There is minimal to no reservoir of excess skin for movement to close a defect, and the poor laxity of the skin does not provide a reservoir of adjacent skin for closure. However, the skin on the neck immediately inferior to the ear does provide
(1) Laxity of the posterior neck provides tissue reservoir for transposition flaps. (2) Advantages of using this flap include the ability to close a large defect, a 1-stage procedure, and good tissue color match. (3) Using a subcutaneous pedicle based on the blood supply of the posterior auricular artery ensures greater chance of flap survival.
References 1. Vergilis-Kalner IJ, Goldberg LH. Bilobed flap for reconstruction of defects of the helical rim and posterior ear. Dermatol Online J 2010; 16:9. 2. Brodland D. Auricular reconstruction. Dermatol Clin 2005;23:23–41. 3. Smith JB, Desciak EB, Eliezri YD. Repair of the posterior ear after Mohs micrographic surgery. Dermatol Surg 2002;28:1073–5. 4. Gladstone HB, Morganroth GS. Ear reconstruction. In: Rohrer TE, Cook JL, Nguyen TH, Mellete JM, editors. Flaps and grafts in dermatologic surgery. China: Elsevier; 2007; pp. 179–90.
Address correspondence and reprint requests to: Diane Trieu, MD, DermSurgery Associates, 7515 Main Street, Suite 240, Houston, TX 77030, or e-mail: [email protected]
41:1:JANUARY 2015
157
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
