RECONSTRUCTIVE CONUNDRUM

Reconstruction of Defects of the Posterior Pinna

Neil J. Mortimer, MRCP, Eugene Tan, FACD, and Paul J. M. Salmon, FRACP

The authors have indicated no significant interest with commercial supporters.

69-year-old white man presented for treatment

of a biopsy-proven, poorly dened, inltrative
basal cell carcinoma of the posterior aspect of the left
pinna. This was excised with Mohs micrographic
surgery, requiring 2 stages to achieve tumor-free

margins. The resultant 2.3 2.2 cm defect involved the

lateral aspect of the posterior pinna but not the helical
rim. Centrally, the defect was devoid of
perichondrium (Figure 1). How would you
reconstruct this defect?

Figure 1. Surgical defect on the posterior pinna with exposed cartilage.

Dermatologic Surgical Unit, Skin Cancer Institute, Tauranga, New Zealand

2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 1076-0512 Dermatol Surg 2015;41:968971 DOI: 10.1097/DSS.0000000000000413

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MORTIMER ET AL

Figure 2. (A) Helical rim advancement flap mobilized on the skin of the posterior pinna. (B) Advancement of the flap
demonstrating closure of the defect.

Resolution
A number of reconstructive options exist for surgical
wounds of the posterior pinna. These include second
intent healing, skin grafting, and ap repairs. All
have their advantages and limitations. Second intent
healing can be prolonged, especially for larger
deeper defects, and necessitates daily wound care.
Resultant brosis may cause distortion of the ear,
particularly if the defect lies close to the free margin
of the helical rim. Second intent healing with delayed
grafting is an option but necessitates time for granulation tissue formation and a second operative
procedure. Flap repairs take advantage of the tissue
reservoirs in the postauricular sulcus and adjacent
scalp/neck (e.g., O-T, single lobed, and bilobed
transposition aps). Because the skin of the pinna is
tightly adherent to the underlying cartilage, they
generally require extensive undermining and may
cause pinning back of the ear and/or distortion of the
exible cartilaginous framework of the pinna.14
Full- or split-thickness grafts are excellent reconstructive options for defects limited to the posterior
surface of the pinna but rely on intact perichondrium
for survival and do not address the loss of soft
tissue in deeper defects.

In this case, the authors were concerned about the

protracted course of healing by secondary intent and
the risk of distortion of the ear. The defect was too
large to permit linear closure, and the exposed cartilage devoid of perichondrium meant that a skin graft
repair was not ideal. After careful consideration,
despite the absence of involvement of the helical rim,
the authors elected to perform a helical rim advancement ap (HRAF) to repair the defect.
The HRAF conventionally has been used as a workhorse ap for the reconstruction of surgical defects
of the helical rim of the pinna.5 However, its utility
for defects of the posterior pinna without involvement of the helical rim has not previously been
described. The authors describe their experience
with the above reconstructive method, which serves
as a useful repair option for selected defects of the
posterior pinna.
Surgical Technique
The ap was designed and marked. The surgical defect
was extended anterolaterally to the anterior helical
sulcus. An incision was then made in the sulcus to the
lobule and a Burows exchange triangle initiated. The

Figure 3. (A) Flap sutured in place. (B) Posterior view of the flap.

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2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

RECONSTRUCTION OF DEFECTS OF THE POSTERIOR PINNA

Figure 4. Six-week postoperative photographs. (A) Side view. (B) Posterior view.

incision was carried through the skin of the anterior

surface of the pinna and the underlying cartilage but
not through the postauricular skin. The skin of the
posterior surface of the pinna was then mobilized by
meticulous dissection immediately above the perichondrium followed by careful hemostasis by electrodessication (Figure 2). This creates the
chondrocutaneous ap based on the skin of the posterior surface of the pinna.
The key stitch precisely approximates the helical rim
with 1 or 2 buried vertical mattress sutures. The Burows triangle in the lobule is excised.
Execution of the ap in this way generates tissue
redundancy on the posterior surface of the pinna,
which normally would be excised but in this case
facilitates the laxity required to close the surgical
defect (Figure 2B).
The ap is then sutured in place using horizontal
mattress sutures at the helical rim to obtain hypereversion and avoid notching (Figure 3). The remaining
incision line is meticulously approximated with
a continuous running suture. The long-term results of
this repair are depicted in Figure 4.

Discussion
Helical rim advancement aps have an undoubted
utility for surgical wounds of the helical rim. They can
either be designed with full-thickness incisions in the
anterior helical sulcus (which often generates
increased superior mobility) or as a partial thickness
incision where the ap is mobilized on the skin of the
posterior pinna.

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When designed according to the latter method,

the ap functions as a Burows exchange advancement ap usually necessitating excision of Burows
triangles within the lobule and on the posterior
surface of the pinna. When applied to selected
defects of the posterior pinna, the excess tissue
generated on the posterior surface of the pinna
facilitates repair of the defect. The use of HRAFs
for defects of the posterior pinna provides an
excellent cosmetic result, preserves contour of the
helical rim, camouages incision lines, and avoids
distortion or pinning back of the cartilaginous
framework of the ear.
The ideal surgical defect lies on the posterolateral
aspect of the pinna with a vertical dimension of up to
2 cm.

Conundrum Keys
(1) Consider the HRAF as a repair option for
carefully selected defects of the posterior pinna
where traditionally the rst choice may be a ap
using the tissue reservoir in the region of the
postauricular sulcus.
(2) The ideal surgical defect lies on the posterolateral aspect of the pinna up to 2 cm in vertical
height.
(3) The posterior ear is highly vascular, and hematoma formation is a risk. Meticulous attention to
hemostasis is crucial.
References
1. Butler CE. Extended retroauricular advancement ap reconstruction of
a full-thickness auricular defect including posteromedial and
retroauricular skin. Ann Plast Surg 2002;49:31721.

DERMATOLOGIC SURGERY

2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

MORTIMER ET AL

2. Krishnan R, Garman M, Nunez-Gussman J, et al. Advancement aps:

a basic theme with many variations. Dermatol Surg 2005;31:98694.

5. Kaufman AJ. Helical rim advancement aps for reconstruction.

Dermatol Surg 2008;34:122932.

3. Vergilis-Kalner IJ, Goldberg LH. Bilobed ap for reconstruction of

defects of the helical rim and posterior ear. Dermatol Online J 2010;16:9.
4. Vergilis-Kalner IJ, Goldberg LH, Landau JM, et al. Perforator-based
myocutaneous pedicle ap for reconstruction of a large defect of the
posterior ear. Dermatol Surg 2012;38:9326.

Address correspondence and reprint requests to: Paul J. M.

Salmon, Skin Cancer Institute, Tauranga, Bay of Plenty
3110, New Zealand, or e-mail: pauls@skincentre.com

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2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.