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Postauricular Artery Island Flap for Subtotal Ear Reconstruction: Expanding Flap Versatility Based on Zones of Regional Perfusion

Reid, Russell R. M.D., Ph.D.; Lee, Michael J. M.D.; Lewis, Victor L. M.D.

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Plastic and Reconstructive Surgery: April 2008 - Volume 121 - Issue 4 - p 213e-214e
doi: 10.1097/01.prs.0000305378.62947.7e
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Sir:

The postauricular artery flap is a workhorse for conchal reconstruction. Previous reports1–4 have focused on flaps directly posterior, or cranial, to the conchal defect. Such “short pedicle” designs are precluded in severe trauma or Mohs’ excision, where both conchal and postauricular subunits are absent. We present a novel design of the postauricular artery flap for conchal replacement that exploits the rich vascular network of this vessel.

A 68-year-old man with basal cell carcinoma of the right ear underwent Mohs’ surgery. The patient exhibited loss of the cymba conchae and the antihelix and partial loss of the helical rim (Fig. 1). In addition, the cranial surface directly behind the ear was absent, negating “revolving door” or direct pull-through of mastoid tissue (Fig. 1). A 3.5 × 3-cm island flap was designed using a Doppler probe, incorporating the occipitomastoid branch of the postauricular artery (Fig. 1, arrow). A fasciocutaneous composite 5 mm inferior to the mastoid prominence was recruited. Judicious use of Doppler ultrasound enabled dissection of a superiorly based flap (Fig. 1). The flap was transposed 180 degrees without tension. After insetting of the flap and primary closure of the donor site, a 0.0012-inch split-thickness right thigh skin graft was applied to the retroauricular Mohs’ defect. Immediate follow-up displayed minimal flap congestion. Long-term follow-up revealed excellent contour and color match of the reconstructed ear (Fig. 2). The patient has had no tumor recurrence, and flap revision via liposuction is pending.

Fig. 1.
Fig. 1.:
A large, through-and-through auricular defect, with extension onto the underlying auriculomastoid skin. A pedicled island flap, based on intraoperative Doppler probe findings, is elevated in an inferior to superior direction (held by Adson forceps), incorporating deep fascia and the perforating branch (arrow).
Fig. 2.
Fig. 2.:
At 1 year postoperatively, the flap has good color match and contour. Flap bulk will be addressed with minor revision via liposuction in the future.

Reconstruction of the ear requires a complete understanding of the intricate arterial supply of this craniofacial appendage. Park et al.3 identified three divisions of the posterior auricular artery (lower, middle, and upper) and based their island flap on the constant upper branch of the middle division. Two arterial networks have been identified that supply the anterior ear.4 The triangular fossa-scapha network is supplied by the upper auricular branch of the superficial temporal artery and collateralized by dominant branches (two or three) from the posterior auricular artery. The conchal network contains two to four perforators that emerge from the posterior auricular artery and perforate the conchal floor. Whetzel and Mathes5 define this vascular territory as a 6 × 11-cm area bordered by the tragus anteriorly, 5 cm from the external auditory canal posteriorly, and 6 cm from the mastoid inferiorly. The current case takes advantage of the entire network, which includes descending cervical, occipitomastoid, inferior, medial, and superior postauricular branches.3–5 Such arborization divides the retroauricular skin into distinct perfusion zones,5 allowing one to tailor a skin flap of varying size and location, depending on the defect size and the donor tissue available. Such versatility is essential when the cranial skin behind the ear is deficient or absent.

Russell R. Reid, M.D., Ph.D.

Section of Plastic Surgery

University of Chicago

Chicago, Ill.

Michael J. Lee, M.D.

Victor L. Lewis, M.D.

Division of Plastic Surgery

Feinberg School of Medicine

Northwestern University

Evanston, Ill.

DISCLOSURE

No authors involved in the production of this communication have any commercial associations that might pose or create a conflict of interest with information presented herein. Such associations include consultancies, stock ownership, or other equity interests, patent licensing arrangements, and payments for conducting or publicizing a study described in the communication. No intramural or extramural funding supported any aspect of this work.

REFERENCES

1. Masson, J. K. A simple island flap for reconstruction of concha-helix defects. Br. J. Plast. Surg. 25: 399, 1972.
2. Jackson, I. T., Milligan, L., and Agrawal, K. The versatile revolving door flap in the reconstruction of ear defects. Eur. J. Plast. Surg. 17: 131, 1996.
3. Park, C., Shin, K. S., Kang, H. S., Lee, Y. H., and Lew, J. D. A new arterial flap from the posterauricular surface: Its anatomic basis and clinical application. Plast. Reconstr. Surg. 82: 498, 1988.
4. Park, C., Lineaweaver, W. C., Rumly, T. O., and Buncke, H. J. Arterial supply of the anterior ear. Plast. Reconstr. Surg. 90: 38, 1992.
5. Whetzel, T. P., and Mathes, S. J. Arterial anatomy of the face: An analysis of vascular territories and perforating cutaneous vessels. Plast. Reconstr. Surg. 89: 591, 1992.

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