Grabb’s Encyclopedia of Flaps Head and Neck

Publishers, 1948.

Chapter 83
Chondrocutaneous Advancement Flap to The Helical Rim
N. H. ANTIA
EDITORIAL COMMENT
This is an excellent procedure for restoring substantial defects of up to 3 cm of the helix of the ear. It gives
predictably good results. Its only drawback is the lowering of the height of the ear. A good portion of the
scar line is not as obvious as noted in the postoperative photographs, when the incision is placed within the
helical sulcus (see diagrams).
Many acquired defects of the ear involve small segments of the helical margin, usually less than a quarter of the
circumference of the ear. Such defects commonly result from the excision of tumors such as basal cell carcinoma
or burns. Although small, the defect is very noticeable, especially in men. The chondrocutaneous advancement
flap is a relatively simple and safe single-staged operative procedure that provides an almost normal contour to
the ear (1, 2).
INDICATIONS
Several techniques have been described for the correction of helical defects, such as postauricular,
cervical, or mastoid flaps or composite grafts. To correct such a defect and produce a good cosmetic result
is difficult because of the intricate nature of the chondrocutaneous sandwich that gives the delicate
configuration to the auricle.
The chondrocutaneous advancement flap recreates the normal delicate contours of the ear that are difficult
to achieve by any other procedure. There is also no donor defect.
FLAP DESIGN AND DIMENSIONS
The principle underlying this procedure is that of advancement of the adjacent intact helical margin as a
chondrocutaneous flap based on a wide postauricular skin pedicle. The ear lobule, which can be quite variable
in size, is also advanced upward with this procedure.
If the defect is large, involving 3 to 4 cm of the helix, a double chondrocutaneous advancement of the helix can
be performed by including the intact cephalic segment of the helix as a second flap (Fig. 83.1). It is important to
extend the triangular tail of this flap right into the depth of the concha so that even after advancement the
pleasing question mark shape of the helix is preserved. When such a large defect is closed by this technique (as
shown in Fig. 83.2), it is often necessary to reduce the size of the contralateral ear to provide earlobe symmetry.
OPERATIVE TECHNIQUE
The technique of the operation is shown diagrammatically in Figure 83.3, and the result is shown in Figure 83.4.
In this case, the scarred margins of the defect were pared to recreate the original defect, and reconstruction was
undertaken as a secondary procedure.
The skin on the lateral surface of the ear and the underlying cartilage are incised along the line of the anthelix
between the helix and the anthelix, and the incision is extended into the soft tissue of the lobule (Fig. 83.3A).

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This is followed by careful dissection of the postauricular skin from the posterior surface of the concha and from
the mastoid (Fig. 83.3B).
This dissection is especially difficult in the region of the groove between the mastoid and the ear, where there
are dense, fibrous adhesions. Care must be taken to preserve the blood supply to
the flap by keeping as close to the cartilage and bone as possible. The chondrocutaneous sandwich, on a wide
and highly vascular pedicle, can now be advanced to close the defect. It is necessary only to obtain accurate
apposition of the skin (Fig. 83.3D), since the cartilage can be held in place by a well-molded dressing.
FIGURE 83.1 A-D: Diagrammatic representation of double chondrocutaneous advancement flaps for
reconstruction of a large (3 to 4 cm) helical defect. (From Antia and Buch, ref. 1, with permission.)
FIGURE 83.2 A: Preoperative appearance of a large superior helical defect. B: Postoperative result. The size of
the contralateral ear was reduced to produce symmetry. (From Antia and Buch, ref. 1, with permission.)
FIGURE 83.3 A-D: Diagrammatic representation of a chondrocutaneous advancement flap from the caudal

portion of the helix for reconstruction of a small (1 to 2 cm) helical defect. (From Antia and Buch, ref. 2, with
permission.)
FIGURE 83.4 A: Preoperative appearance of a small helical defect. B: Postoperative result. Note how the lobule
has been pulled upward and the circumference of the ear has decreased. (From Antia and Buch, ref. 2, with
permission.)
SUMMARY
The chondrocutaneous advancement flap is a simple, safe, one-stage procedure that gives excellent results
for correction of partial losses of the helix of the ear.
References
1. Antia NH, Buch VI. Chondrocutaneous advancement flap for the marginal defect of the ear. Plast Reconstr
Surg 1967;39:472.
2. Antia NH. Repair of segmental defects of the auricle in mechanical trauma. In: Tanzer R, Edgerton M, eds.,
Symposium on Reconstructive Surgery of the Auricle. St. Louis: Mosby, 1974;218-220.

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Chapter 84
Antegrade Triangular Composite Ear Flap for Helix-Scapha
Defects of The Ear
R. V. ARGAMASO
C. A. RHEE
EDITORIAL COMMENT
This is an outstanding method of ear reconstruction; it extends Antia's procedure for the lateral ear defect.
The result is an ear that appears almost normal but is slightly smaller than on the unoperated side.
The antegrade triangular chondrocutaneous flap is useful for single-stage reconstruction of defects measuring
less than 2.0 cm that involve the helix scaphal region of the upper ear (1, 2, 3).
INDICATIONS
The antegrade triangular composite ear flap is a simple method that can be used to correct defects or
deformities of 2.0 cm or
less in the helix or scaphal region of the upper segment of the ear (Fig. 84.1). This technique offers the
advantages of a single-stage procedure and obviates the need for the additional use of cartilage and skin
grafts. A disadvantage is that, depending on the extent of the defect, the overall size of the ear is reduced.
FIGURE 84.1 A,B: Helix-scapha defect of the ear.
ANATOMY
The auricle or pinna has a somewhat oval shape; the upper half is usually wider and gradually tapers bluntly
toward the lobe. At the helical rim, the tail of the rim and antitragus, the skin can be separated easily from the
underlying cartilage. Therefore, it is possible to skeletonize the entire lower portion of the ear and to advance the
skin mantle superiorly. The blood supply of this flap is based in the skin pedicle of the lower pole of the ear.

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FIGURE 84.2 A,B: Triangular chondrocutaneous flap elevated.
FLAP DESIGN AND DIMENSIONS
A skin marking for the incision is drawn on the lateral side, along the most anterior rim of the defect, and arching
downward toward the fold between the helix and anthelix just above the ear lobe. A second marking is drawn
along the margin of the upper stump of the helix.
OPERATIVE TECHNIQUE
The incision is made through and through the lateral skin, cartilage, and skin of the medial ear, creating a
triangular chondrocutaneous flap (Fig. 84.2). At the inferior end of the incision, the skin is elevated from the
medial and lateral sides of the concha (Figs. 84.3 and 84.4). The tail of the helix is cut and detached from the
main cartilaginous portion of the ear. The blood supply of the composite flap is now based on
its inferior skin pedicle. Detachment of the cartilage facilitates advancement of the tail of the helix and antegrade
advancement and rotation of the triangular composite flap over the defect. An incision then is made at the upper
stump to open up a triangular space for accepting the apex of the chondrocutaneous flap.
FIGURE 84.3 A,B: Skin elevated from medial concha.
Closure is accomplished in layers and includes the approximation of cartilage to cartilage, with particular
attention to the helical margins. This maneuver brings the helical rims together and recreates the scaphoid fossa

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(Fig. 84.5).
FIGURE 84.4 A,B: Skin elevated from lateral ear.
SUMMARY
An antegrade triangular chondrocutaneous flap can be used in one stage for reconstructing defects of less
than 2.0 cm that involve the helix scaphal region of the upper ear.
FIGURE 84.5 A,B: End result after antegrade advancement and rotation of triangular composite flap.
References
1. Argamaso RV, Lewin M. Parial deformities of the ear. In: Hinderer UT, od. Plastic Surgery, vol. 1,
Amsterdam: Elsevier, 1992; 249-255.
2. Argamaso RV. Ear flaps. Ear Nose Throat 1972;51:310.
3. Argamaso RV, Lewin ML. Repair of partial ear loss with local composite flaps. Plast Reconstr Surg
1968;42:437.

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Chapter 85
Flap Correction for Cryptotia
R. V. ARGAMASO
EDITORIAL COMMENT
This is an excellent flap for the correction of cryptotia, and all the editors recommend it to our readers.
Correction of cryptotia is important not only from the standpoint of appearance, but it also allows the patient
to wear glasses so that the helical portion of the rim frames does not slip off the ear.
A retroauricular retrograde skin flap can be used to correct a congenital, bilateral, ear deformity. The procedure
places scar lines in areas that reduce scar visibility and also circumvents the need for skin grafts.
INDICATIONS
The term cryptotia is applied to a congenital anomaly of the ear characterized by the disappearance of the
superior pole from view; the pole telescopes and hides beneath the scalp. When the invaginated upper pole
is retracted out from under the scalp, the helix usually appears intact; however, the scapha may have some
deformity associated with a rather sharply folded superior antihelical crus. A third crus may be present. After
retraction is released, the upper pole returns into the scalp pocket.
Elevation of the upper pole of the ear from the side of the head is indicated for aesthetic reasons and also
offers convenience and support for eye glasses or hearing aids. Many methods of releasing the upper pole
have been described (1, 2, 3, 4, 5, 6). Elevation from the side of the head creates a skin
defect of the scalp and on the medial aspect of the ear. This open area requires coverage with adjacent
scalp flaps, skin grafts, or a combination of these. The resultant scalp scars are readily seen but may be
hidden if the hair is kept long.

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FIGURE 85.1 A-C: Artist's rendition showing outline of skin incision on mastoid skin along the retroauricular
sulcus, terminating anteriorly as a Z. Note back-cut toward the earlobe. D-F: Upper pole is released and
triangular flaps are interposed. G-I: Retrograde flap is rotated and set in place.
The retrograde medial-ear skin flap is a random flap that is useful for the correction of cryptotia (7) as well
as for defects of the lower pole of the ear (8). Scar lines are placed in areas which limit scar visibility, and
the need for skin grafts is circumvented.
ANATOMY
The primary blood supply to the medial skin of the ear comes from the posterior auricular artery. Its branches
freely anastomose with those vessels on the lateral surface of the ear coming from branches of the superficial
temporal artery. The rich network of anastomosing vessels, arranged randomly at the periphery of the ear, safely
permits elevation of skin flaps on the medial side, based virtually from any direction.

FIGURE 85.2 A: Preoperative frontal view. B: Postoperative frontal view. C: Preoperative lateral view. D:
Postoperative lateral view. E: Preoperative back view. F: Postoperative back view.
FLAP DESIGN AND DIMENSIONS
The extent of the skin incision is outlined, with the upper pole retracted from its pocketed position in the scalp.
Starting at about the level of the earlobe, the incision follows along the auricular cephalic sulcus on the mastoid
side and continues superiorly, arching anteriorly, and terminating at the helical crus, where a Z-plasty is also
outlined (Fig. 85.1A-C). At the inferior extremity of this skin marking, a small back-cut is marked and extends
toward the earlobe, which will allow further rotation of the medial-ear skin flap. Thus, the flap encompasses
nearly the entire medial skin of the ear based on a broad pedicle along the helical margin.
OPERATIVE TECHNIQUE
The incision is made along the predetermined skin marking. The segment of ear cartilage buried beneath the
scalp is liberated from its soft-tissue moorings by transecting its attachments to the periosteum of the temporal
bone. When detachment is complete, the upper pole of the ear stays out of the scalp and assumes its normal
projection. The skin flap then is elevated in a retrograde manner from the perichondrium toward the helical rim.
The communicating branches through the cartilage (perforators) are identified and electrocoagulated.
Electrocoagulation of bleeders on the flap side should be minimized or avoided. Dissection toward the helix is
done carefully, as close to the perichondrium as possible, to avoid interruption of the intercommunicating vessels
crossing over the helix from the lateral side of the ear.
The retrograde skin flap then is rotated superiorly. Additional superior advancement of the flap is gained by a
back-cut. The medial ear skin thus stretched and expanded toward the upper pole becomes sufficient to
resurface the medial side of the exteriorized segment of the ear. A small dogear that develops inferiorly is
trimmed. The small triangular skin flap, based anteriorly at the region of the helical crus, is transposed in Z-plasty
fashion to recreate and maintain a deep auricular cephalic sulcus. The flaps finally are inset using fine sutures of
5-0 or 6-0 nylon (Fig. 85.1D-F). A conforming dressing is applied with mild compression.

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CLINICAL RESULTS
In the retrograde flap, edema is to be expected during the early postoperative stage. This edema gradually
subsides within a period of days or a few weeks. The scar lines are found in inconspicuous areas along the
postauricular sulcus, and the hairline is not disturbed (Fig. 85.2).
SUMMARY
The retroauricular retrograde skin flap is useful for the correction of cryptotia. Placement of the scar lines
along the retroauricular groove minimizes their exposure from casual frontal, lateral, or back views.
References
1. Burian F. Correction of pocketed auricle. In: The plastic surgery atlas, vol. 2. London: Butterworth,
1967;470.
2. Cowan RJ. Cryptotia. Plast Reconstr Surg 1969;27:209.
3. Fukuda O. Otoplasty of cryptotia. Jpn J Plast Reconstr Surg 1968;11:L117.
4. Pollack WJ. Technique for correction of cryptotia: Case report. Plast Reconstr Surg 1969;44:501.
5. Washio H. Cryptotia: pathology and repair. Plast Reconstr Surg 1973;52:648.
6. Wesser DR. Repair of a cryptotic ear with a trifoil flap. Plast Reconstr Surg 1972;50:192.
7. Argamaso RV. Cryptotia: its surgical correction. Ann Plast Surg 1979;2:109.
8. Argamaso RV. Techniques for the reconstruction of the earlobe. Philippine J Surg Spec 1979;35:31.

Chapter 86
Retroauricular Bipedicle Skin Flap for Partial Ear Reconstruction
S. ZENTENO ALANIS
Partial losses of the auricle often give the misleading impression that the defect is smaller than it is in reality.
INDICATIONS
When the defect is in the posterior margin of the ear, a large bipedicle flap of posterior ear skin is
recommended (see Chapter 81). These tissues are thin, well vascularized, pliable, and of the same color as
the rest of the ear.
If the defect is in the superior portion of the external ear, a cartilage graft may be required for support. If the
defect is in the inferior portion of the ear, there is no need for cartilage because the force of gravity does not
alter the shape obtained with a skin flap (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18).
ANATOMY
The bipedicle flap from the retroauriculomastoid area has a superior pedicle located next to the helix insertion
and an inferior pedicle behind the earlobe (Fig. 86.1). The postauricular artery is included in the flap.
FLAP DESIGN AND DIMENSIONS
This flap is about 2 cm wide and 5 cm long. The anterior line of the flap is drawn on the posterior ear surface,
leaving a portion of skin about 2 mm wide between this line and the edge of the defect. The posterior line of the
flap will be parallel to the anterior line and located next to the retroauricular hairline (Figs. 86.1 and 86.2B). The
transverse measurement must be more than double the width of the defect.
OPERATIVE TECHNIQUE
The bipedicle skin flap is raised and folded longitudinally on itself. The anterior edge of the flap is sutured to the
anterior edge of the ear defect. The posterior edge of the flap is sutured to the 2-mm skin bridge left behind
when the anterior edge of the flap is incised. The skin graft that will cover the flap donor area then is sutured to
the posterior edge of the same skin bridge (Fig. 86.2C).
In the case of major loss of the posterior margin of the ear, a cartilage segment taken from the ipsilateral concha
as a composite flap or a cartilage graft taken from the contralateral ear will be required to maintain the shape of
the ear (Fig. 86.3C).
The second stage is performed 3 to 4 weeks later. Both pedicles are divided so that an extra portion of skin is
included to provide helical continuity.
SUMMARY
The retroauricular bipedicle flap is used for large defects of the posterior margin of the external ear.

FIGURE 86.1 A: Posteroanterior and lateral views of the flap design. B: Mobilization of the flap to cover the
posterosuperior marginal defect. The flap donor area has been skin grafted. C: Final result after
transposing the flap pedicles. A cartilage graft has been inserted to support the helical rim.
FIGURE 86.2 A: Loss of a portion of the helix as a result of a human bite. B: Posterior view to demonstrate
the outline of the retroauricular bipedicle skin flap. C: The flap was lifted with a segment of conchal
cartilage. A skin graft was sutured to the flap donor area. A tie-over pressure dressing will be used for the
skin graft. D: The pedicles of the flap have been divided. E: Final appearance of the reconstructed ear.

FIGURE 86.3 A: Defect of half of the helical rim, superior crus of the anthelix, and triangular fossa as a
result of trauma. B: After transposition of the skin-flap pedicles. (Continued)
FIGURE 86.3 Continued. C: A cartilage graft was taken from the contralateral ear. D: Final appearance of
the reconstructed ear.
References
1. Maliniac JW. Reconstruction for partial loss of the ear: case reports. Plast Reconstr Surg 1946;1:124.
2. Stefanoff DN. Auriculomastoid tube pedicle for otoplasty. Plast Reconstr Surg 1948;3:352.
3. Lewin ML. Formation of the helix with a postauricular flap. Plast Reconstr Surg 1950;5:432.
4. Cronin TD. One-stage reconstruction of the helix: two improved methods. Plast Reconstr Surg 1952;9:547.
5. Spina VA. A simpler method of partial reconstruction of the external ear. Plast Reconstr Surg 1954;13:488.
6. Gillies, HD, Millard, DR. The principles and art of plastic surgery. Boston: Little, Brown, 1957. P. 312.
7. Converse, JM. Reconstruction of the auricle. Part II. Plast Reconstr Surg 1958;22:230.
8. Luna, C. Partial auricular plastic surgery. Rev Lat Am Cirug Plast 1961;5:28.

9. Navabi, A. One-stage reconstruction of a partial defect of the auricle. Plast Reconstr Surg 1964;33:77.
10. Pigossi, N. Repair of partial losses of the external ear. Rev Lat Am Cirug Plast 1965;9:35.
11. Steffensen, WH. A method of total ear reconstruction. Plast Reconstr Surg 1965;36:97.
12. Cosman B, Crikelair G. The composed tube pedicle in ear reconstruction. Plast Reconstr Surg
1966;37:517.
13. Millard DR. The chondrocutaneous flap in partial auricular repair. Plast Reconstr Surg 1966;27:523.
14. Zenteno Alanis S. Reconstruccíon de pabellon auricular. Rev Anales Soc Otorinolaringol 1968.
15. Zenteno Alanis S. Creación de la Clínica de 1° y 2° Arcos Branquiales. Rev Lat Am Cirug Plast
1970;14:65.
16. Orticochea M. Reconstruction of partial loss of the auricle. Plast Reconstr Surg 1971;47:220.
17. Zenteno Alanis S. Severe problems in total ear reconstruction. In: Transactions of the 5th International
Congress of Plastic and Reconstructive Surgery. Melbourne, Australia: Butterworth, 1971.
18. Zenteno Alanis S. Reconstruccíon de Pérdidas Parciales del Pabellón Auricular. Trib Med Mex
1975;29:A3.

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Chapter 87
Chondrocutaneous Conchal Flap to The Upper Third of The Ear
J. E. DAVIS
Loss of the upper third of the ear can be repaired in one stage with a chondrocutaneous flap raised from the
concha.
INDICATIONS
This type of reconstruction is indicated in deformities resulting from trauma and after surgical ablation, but in
congenital microtia the concha is too small to provide donor tissue (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12).
ANATOMY
The very narrow pedicle is at the helix radicis. The blood supply is of the random-pattern type, and the pedicle
itself consists of three layers: skin, cartilage, and skin.
FLAP DESIGN AND DIMENSIONS
The flap is unique because it can be mobilized on a very small pedicle as a result of the abundant blood supply
at this point.
OPERATIVE TECHNIQUE
An incision is made (Fig. 87.1) through the skin and conchal cartilage. The incision commences just behind the
radix, falls below the inferior crus, runs along the anthelical insertion at the conchal floor, and continues forward
at the lower cavum conchae until reaching the posterior border of the external auditory meatus. It comes up
vertically inside the tragus to the anterior border of the helix radicis at the sulcus auricularis superior.
Then the dissection proceeds under the posterior conchal perichondrium. The chondrocutaneous flap is raised
with hooks until it remains attached by a pedicle of only about 8 mm at the radix helicis.
The flap is now rotated upward into position to form the ear dome (Figs. 87.2 and 87.3C). The position is held by
the elasticity of the cartilage as the flap tends to return to its original position, and one cartilage border presses
gently against the other. These borders are trimmed until they coapt exactly. There is no need to suture the
cartilages together because the position is maintained adequately with skin sutures. A mastoid skin flap can be
raised to cover the border and posterior surface of this upper dome. The raw surface on the conchal
floor is grafted with full-thickness contralateral retroauricular skin.

FIGURE 87.1 The solid and dotted lines outline the chondrocutaneous conchal flap, which will be rotated
upward on its narrow pedicle. The postauricular skin is dissected from the auricular cartilage at the margins of
the upper ear defect.
FIGURE 87.2 The chondrocutaneous conchal flap has been rotated to reconstruct the upper third of the external
ear. A mastoid skin flap covers the exposed cartilage.

FIGURE 87.3 A: Ulcerated skin cancer of superior helix of the left external ear. B: Operative photograph after
excision of the skin cancer. C: The chondrocutaneous flap is rotated into position. D: Postoperative appearance.
(From Davis, ref. 10, with permission.)
CLINICAL RESULTS
The resulting aesthetic appearance of the ear is not perfect because the radix helicis pedicle is prominent in
the area normally occupied by the fossa triangularis depression (Fig. 87.3D). However, most of my patients
were satisfied, and only one wished to have a secondary procedure to form the fossa triangularis.
SUMMARY
A chondrocutaneous conchal flap can be used to reconstruct the upper third of the ear.
References
1. Adams WM. Construction of the upper half of the auricle utilizing composite conchal cartilage graft with
perichondrium attached on both sides. Plast Reconstr Surg 1955;16:88.
2. Crikelair GF. A method of partial ear reconstruction for avulsion of the upper portion of the ear. Plast
Reconstr Surg 1956;17:438.

3. Antia NH, Buch VI. Chondrocutaneous advancement flap for the marginal defects of the ear. Plast
Reconstr Surg 1967;39:472.
4. Argamaso RV, Lewin ML. Repair of partial ear loss with local composite flap. Plast Reconstr Surg
1968;42:437.
5. Nagel F. Reconstruction of partial auricular loss. Plast Reconstr Surg 1972;49:340.
6. Davis JE. On auricular reconstruction. Internatl Microform J Aesthet Plast Surg Otoplasty 1972:1.
7. Davis JE. Discussion. In: RC Tanzer, MT Edgerton, eds. Symposium on reconstruction of the auricle. St.
Louis: Mosby, 1974;247.
8. Davis JE. Auricle Reconstruction. In: MN Saad, P Lichtvelt, eds. Reviews of plastic surgery. Amsterdam:
Excerpta Medica, 1974;129.
9. Lewin ML, Argamaso RV. Repair of major defects of the auricle in mechanical trauma. In: Tanzer RC,
Edgerton MT, eds. Symposium on reconstruction of the auricle. St. Louis: Mosby, 1974;221.
10. Davis JE. Acquired deformities of the auricle. In: Converse JM, ed. plastic and reconstructive surgery, 2d
ed. Philadelphia: WB Saunders, 1977; 1755.
11. Converse JM. Acquired deformities of the ear. In: Converse JM, ed. Plastic and reconstructive surgery,
2d ed. Philadelphia: WB Saunders, 1977; 1724.
12. Brent B. Reconstruction of traumatic ear deformities. In: Furnas DW, ed. Clinics in plastic surgery:
deformities of the external ear. Philadelphia: WB Saunders, 1978;441.

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Chapter 88
Retrograde Auricular Flap for Partial Ear Reconstruction
H. W. LUEDERS
The retrograde auricular flap is useful for reconstruction and enlargement of an ear that has been burned,
avulsed, or injured in such a manner that the upper part of the scapha or fossa triangularis has been lost, leaving
a residual mass of skin and cartilage close to the concha (1).
ANATOMY
The posterior surface of the ear is supplied principally by terminal branches of the auricular artery from the
postauricular artery. Care must be taken not to injure this artery in its location along the postauricular groove
when dissecting over the mastoid.
FLAP DESIGN AND DIMENSIONS
The postauricular skin is used as the base to carry the composite skin and cartilage to the new enlarged position
of the ear rim. The flap base extends from the anterior scalp to the mastoid.
OPERATIVE TECHNIQUE
The anterior skin and cartilage are incised on the remaining ear mass, starting at the onset of the helix anteriorly
and curving to the temple (Figs. 88.1 and 88.2). The other inferior incision starts at the helix anteriorly and
proceeds across the ear cartilage toward the opposite helical rim, creating a triangular flap anteriorly up to the
limit of the temple. It is through the inferior incision that the dissection is carefully taken just to the postauricular
skin, and the skin and subcutaneous tissue are dissected off the remaining concha onto the mastoid groove and
off the mastoid and temple. To mobilize this flap and give it freedom to move upward and backward, an incision
is made transversely in the temple skin.
The skin defect may be so large anteriorly that it is advantageous to elevate a preauricular superiorly based flap
to fill in the defect (Fig. 88.3). This has the advantage of wedging the upper limb in place. The defect created by
the advancing helix is covered with a full-thickness skin graft or a thick, split, nonperforated skin graft. The graft
is placed in the exposed subcutaneous fat of the postauricular skin composite flap. The graft is sutured in and
immobilized by a tie-over dressing over
nonadherent gauze. A subcutaneous suture placed from the scalp to the flap and back to the point of origin and
tied over a bolster may help support the flap in its new position. The rest of the ear is splinted with saline-
moistened gauze and a bulky dressing.

FIGURE 88.1 A-C: Case 1. The patient was 34 years old when both ears were burned in May 1959, the right
more severely. Surgery of the ear was performed in 1960. Preoperative ear height was right ear 5.0 cm and left
ear 6.2 cm. A pedicle suspension suture was fixed to a bolster. (From Lueders, ref. 1, with permission.)
FIGURE 88.2 Case 1. A: Preoperative appearance. B: Postoperative appearance. Increase in height of right ear
was 1.5 cm. (From Lueders, ref. 1, with permission.)

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FIGURE 88.3 A-C: Case 2. The patient was 43 years old when burned in February 1962. Surgery of the ear was
performed in September 1962. Preoperative ear height was right ear 5.0 cm and left ear 6.5 cm. Postoperative
height of the right ear was 6.5 cm. Note: The defect represents the pedicle of postauricular skin advanced off the
concha. (From Lueders, ref. 1, with permission.)
CLINICAL RESULTS
On completion of the dissection, the tip of the flap may be blue. Carefully placed dressings that avoid undue
pressure
have prevented skin losses. Long-term follow-up demonstrates no loss of position or problems. The
technique allows the formation of a framework of cartilage in the ear rim in the first stage, to which
additional tubed pedicles can be attached to shape the ear further (Fig. 88.4). To avoid creating an ear that
appears vertical or whose axis is forward, the initial temple incision should be curved back toward the
mastoid. On the average, a 1.5-cm increase in the vertical height of the ear can be anticipated by the initial
flap procedure.

FIGURE 88.4 Case 2: A: Preoperative view showing loss of the postauricular groove. B: Postoperative
view. Increase in height of the right ear was 1.5 cm. Axis of ear is anterior. C: Anterior view of reconstructed
ear. D: Lateral postoperative view with completed neck tubed pedicle. (From Lueders, ref. 1, with
permission.)
SUMMARY
A retrograde auricular flap can be used to reconstruct partial ear losses that involve the upper part of the
ear.
Reference
1. Lueders HW. One-stage enlargement of the burned ear. Plast Reconstr Surg 1966;37:512.

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Chapter 89
Subcutaneous Pedicle Flap for Reconstruction of The Anterior
Surface of The External Ear
J. K. MASSON
EDITORIAL COMMENT
This is an easy and reliable technique to reconstruct full-thickness defects on the lateral surface of the ear
using postauricular skin. When planning the flap, one should make sure that the subcutaneous vascular
pedicle lies at or close to the center of the defect.
After excision of benign or malignant lesions from the helix and conchal regions of the external ear, the defect, if
small, can be sutured directly. More often, however, it may be of such size or in such a location that a free graft
or a local flap is needed for satisfactory repair. A simple skin flap on a subcutaneous pedicle from the uninvolved
postauricular surface of the ear and the adjacent mastoid area has been useful in repairing a number of defects
that involve the anterior skin surface and the underlying cartilage (1).
INDICATIONS
The main advantage offered by the subcutaneous pedicle flap is its ease of application. The flap provides
an ideal color match and does not require the special dressing techniques that are necessary for
immobilization of a free graft.
The flap is not limited to the concha, as Figures 89.1 and 89.2 might suggest, but in fact can be used in the
triangular and
scaphoid fossa areas. The flap has been used to cover a large part of the external canal and can be used
even for some defects involving the helical rim. In one extreme case, a large flap was used to provide
coverage for the entire anterior surface of the ear out to the helical rim, which had been avulsed in an
automobile accident.

FIGURE 89.1 A: Postauricular subcutaneous pedicle flap showing incision extending through ear. B: Flap
is rolled or pulled through to the anterior surface. (Continued)
FIGURE 89.1 Continued. C,D: Flap is brought forward and sutured in place. (From Masson, ref. 1, with
permission.)
FIGURE 89.2 Cross section through ear at level of external auditory canal. A: Lesion in concha. B:
Remainder of flap incised and undermined. C-E: Flap pulled through and sutured to anterior surface of the
ear. F: Flap sutured into place and the donor site closed primarily. (From Masson, ref. 1, with permission.)
ANATOMY
The fairly rich blood supply to the external ear arises from the external carotid artery by way of the superficial
temporal artery in front and from the posterior auricular artery behind. The venous drainage enters the superficial

temporal vein in front and the external jugular vein below.
From the medial aspect of the ear and the posterior aspect of the auditory meatus, the lymphatic vessels collect
in the mastoid glands at the mastoid tip. The efferent lymphatic trunks enter the deep cervical chain near the
origin of the sternocleidomastoid muscle. The lymphatic vessels of the external ear drain to the anterior or
preauricular glands and, to some extent, to the glands about the parotid and eventually into the deep cervical
chain.
FLAP DESIGN AND DIMENSIONS
After excision of the lesion from the anterior (lateral) surface of the ear, including the cartilage immediately
beneath the tumor, a flap about the same size as the skin defect is marked out on the postauricular skin,
overlapping the palpable margin of the surgical defect, and extending onto the cephaloauricular sulcus and
mastoid area (see Figs. 89.1 and 89.2).
FIGURE 89.3 A: Postauricular flap mobilized on a subcutaneous pedicle after excision of a basal cell carcinoma
of the anterior surface of the concha. Note the opening through to the anterior surface. B: Flap fits the defect
with ear pushed back to the head.
OPERATIVE TECHNIQUE
This roughly circular flap is incised around its borders, coming through on one border into the defect on the
anterior surface of the pinna. The margins of this skin and subcutaneous flap are undermined quite generously,
preserving a pedicle of subcutaneous tissue roughly in the center of the island-like postauricular flap.
Now, with the ear pushed back, the flap is apparent through the perforating defect in the external ear. With a
hook or tissue forceps, the flap margins are brought through the defect to the anterior surface of the ear and
secured with interrupted skin sutures about the entire periphery of the flap. This closes the operative defect on
the lateral surface (Figs. 89.3 and 89.4).
The donor area of the flap behind the ear then is closed directly. Only a light protective dressing is necessary
over the ear for the first postoperative day.
CLINICAL RESULTS
In no case has there been any circulatory disturbance or unsatisfactory healing, although these possibilities
must be considered and theoretically could happen. The final appearance after healing is complete has
been excellent.

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SUMMARY
The subcutaneous pedicle flap is a simple, reliable method of closing defects on the anterior surface of the
external ear.
FIGURE 89.4 A: Postauricular subcutaneous pedicle flap for closure of a defect in the upper part of the
anterior ear. B: Flap in the triangular fossa 3 days after operation.
Reference
1. Masson IK. A simple island flap for reconstruction of concha-helix defects. Br J Plast Surg 1972;25:399.

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Chapter 90
Retroauricular Dermal Pedicled Skin Flap to The Ear
A. J. RENARD
Techniques described to correct defects of the external ear usually fall into two categories. The first includes
circumference-reducing procedures with the necessary removal of normal tissue and a resulting small ear (1, 2,
3, 4). The second includes various techniques designed to maintain the size of the ear by interposition of a flap
or graft or both (5, 6, 7, 8, 9). The use of a retroauricular flap for reconstruction of the auricle through an opening
in the cartilage is well known. The flap described in Chapter 88 uses this technique; however, it is based on a
rather nonmobile subcutaneous pedicle (10).
ANATOMY
This is usually a random-pattern skin flap (11, 12). It is not uncommon to find a direct cutaneous artery at its
base (Fig. 90.1). When this is the case, this retroauricular flap is an axial-pattern flap, receiving its blood supply
in a retrograde fashion by the anastomosis between the superficial temporal artery and the retroauricular artery
(Fig. 90.2).
FLAP DESIGN AND DIMENSIONS
The retroauricular dermal pedicled skin flap is designed as an ellipse (instead of a triangle) with its long axis
oriented slightly obliquely, downward, and forward (Fig. 90.3). This orientation is important because as the donor
defect is closed, the base of the flap is in a position that avoids distortion and undue tension on its dermal
pedicle (Fig. 90.4). The base of the flap is deepithelialized over a length of about 1.5 to 2 cm. The greatest width
usually measures approximately 2 to 3 cm (Fig. 90.3A).
FIGURE 90.1 The skin behind the concha is undermined to allow passage of the flap. The asterisk indicates the
presence of a small direct cutaneous artery occasionally found in the base of the flap.

FIGURE 90.2 Blood supply around the ear. There is an anastomosis between the superficial temporal artery and
the retroauricular artery. When the retroauricular flap is elevated with its dermal pedicle based superiorly, the
blood supply is maintained in a retrograde fashion by the anastomosis between the two arteries.
FIGURE 90.3 A-C: The flap is designed as an ellipse with its axis oriented downward and slightly forward. The
base of the flap is deepithelialized over a length of about 2 cm.
FIGURE 90.4 The flap is tunneled under the skin to be delivered centrally or peripherally. The base of the flap is
in a position that avoids distortion at the time of closure of the defect.

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FIGURE 90.5 A-C: For peripheral lesions, the flap is carried directly to the defect.
OPERATIVE TECHNIQUE
Once the flap is elevated, it can be used in two ways. It can be carried directly to a helical defect for peripherally
located lesions (Figs. 90.5 and 90.6), or it can be tunneled through an opening made in the cartilaginous
framework for use on the lateral surface of the ear (Figs. 90.7 and 90.8). This hiatus should be made wide
enough to avoid constriction of the pedicle. The dermal deepithelialized surface of the pedicle always remains in
apposition to the deep dermis of the overlying retroauricular skin (see Fig. 90.4). The distal portion of the flap is
then trimmed to fit the contour of the defect (Figs. 90.5C and 90.7C). The retroauricular donor site can be closed
with a minimum of tension.
FIGURE 90.6 A: A 63-year-old white man with a squamous cell carcinoma of his left ear located at the superior
helix. B: The lesion was removed and the defect was closed with a retroauricular flap elevated on a
deepithelialized dermal pedicle and carried directly to the defect behind the cartilaginous framework. (From
Renard, ref. 11, with permission.)

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CLINICAL RESULTS
In a small series of patients seen by the author, all the flaps have survived, the suture line of the flap donor
site healed well, and aesthetic results have been quite satisfactory.
SUMMARY
The retroauricular flap based on a dermal pedicle provides coverage for ear defects in one stage without
the need to sacrifice healthy tissue. It can be used for peripherally as well as centrally located lesions.
FIGURE 90.7 A-C: For centrally located lesions, the flap is brought through the cartilaginous framework
after removing a strip of cartilage. The hiatus in the cartilaginous framework should be made wide enough
to avoid constriction of the pedicle.
FIGURE 90.8 A: A 28-year-old white man with a crush-avulsion injury of the skin and cartilage of the
concha, anthelix, and scapha of his left ear. B: The retro-auricular flap based on its dermal pedicle was

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brought through the cartilaginous framework to the lateral surface of the ear. (From Renard, ref. 11, with
permission.)
References
1. Crikelair GF. A method of partial ear reconstruction for avulsion of the upper portion of the ear. Plast
Reconstr Surg 1956;17:438.
2. Antia NH, Buch VI. Chondrocutaneous advancement flap for marginal defect of the ear. Plast Reconstr
Surg 1967;39:472.
3. Tanzer RC, Belluci RJ, Converse JM, Brent B. Deformities of the auricle. In: Converse JM, ed.,
Reconstructive plastic surgery. Philadelphia: WB Saunders, 1977; Chap. 35.
4. Songcharoen S, Smith RA, Jabaley M. Deformities of the external ear: tumors of the external ear and
reconstruction of defects. Clin Plast Surg 1978;5:447.
5. Pegram M, Peterson R. Repair of partial defect of the ear. Plast Reconstr Surg 1956;18:305.
6. Kazanjian VH. Surgical treatment of congenital deformities of the ears. Am J Surg 1958;95:185.
7. Owens N. An effective method for closing defects of the external auditory canal. Plast Reconstr Surg
1959;23:381.
8. Gingrass RP, Pickrell KL. Techniques for closure of conchal and external auditory canal defects. Plast
Reconstr Surg 1968;41:568.
9. Nagel F. Reconstruction of a partial auricular loss: case report. Plast Reconstr Surg 1972;49:340.
10. Masson JK. A simple island flap for reconstruction of concha-helix defects. Br J Plast Surg 1972;25:399.
11. Renard A. Postauricular flap based on a dermal pedicle for ear reconstruction. Plast Reconstr Surg
1981;68:159.
12. Tanzer RC. Postauricular flap based on a dermal pedicle for reconstruction (Discussion). Plast Reconstr
Surg 1981;68:165.

Chapter 91
Auricular, Preauricular, and Postauricular Skin Flaps to The
External Auditory Canal
W. B. MACOMBER
J. D. NOONAN
Stenosis of the external auditory canal is an infrequent but serious consequence of congenital malformation,
auricular trauma, or surgical extirpation. Even relatively minor scarring can cause marked functional and physical
impairment. Not only is there a possibility of hearing deficit, but there is also the probability of chronic
inflammation and infection.
INDICATIONS
The use of skin grafts may provide a temporary solution; however, late results have shown that the ongoing
process of wound contraction invariably produces further reduction in the lumenal diameter. To rectify this
problem, a variety of local flaps can be used to break up the concentric scarring (1, 2, 3, 4).
ANATOMY
The vascularity of these flaps is based on the rich dermal network that exists in this region arising from both the
preauricular and postauricular vessels.
OPERATIVE TECHNIQUE
Conchal Skin Flap
This is an excellent choice, provided the auricular tissue has not been damaged by antecedent trauma. Based
either inferiorly (Fig. 91.1) or superiorly, the entire conchal skin and subcutaneous tissue can be elevated and
transposed across the meatus of the external auditory canal. Care must be taken not to denude the conchal
cartilage of its perichondrium, and a relatively wide base ensures flap viability. The flap donor site is usually
closed with a skin graft.
Preauricular Flap
The preauricular flap (Fig. 91.2) is based inferiorly to minimize the arc of rotation; however, care must be taken,
particularly in men, to avoid pulling the sideburn immediately adjacent to or onto the ear itself at the time of
closure of the flap donor site. To avoid this untoward result, the postauricular flap is quite a satisfactory
alternative.
Postauricular Flap
This flap is outlined in the retroauricular area over the mastoid prominence immediately adjacent to the
postauricular sulcus. The flap usually measures 3 to 4 cm long and at least 1 cm wide. The base is located
below the level of the external auditory canal, separated only by the conchal portion of the ear. The flap then is
elevated just above the periosteum and tunneled through the concha, with the small portion of the flap within the
tunnel being deepithelialized.
On completion of any of these operations, a Xeroform- or mineral oil-soaked gauze packing is placed into the
newly formed canal and left there for 7 to 10 days. This dressing is repeated once or twice until adequate wound

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healing is appreciated. At this point, a soft rubber tube or ear plug of appropriate size is introduced into the
external auditory canal and maintained there until the scar has softened satisfactorily. The plug is removed
periodically and the canal is irrigated to avoid buildup of cerumen.
FIGURE 91.1 A: Outline of the conchal skin flap. B: Conchal skin flap in place with skin graft applied to the
donor site. C: Preoperative stenosis of the auditory canal. D: Postoperative result following meatus
reconstruction with a conchal skin flap. (From Macomber, ref. 4, with permission.)
CLINICAL RESULTS
The resulting orifice is quite patulous, and the untoward effect of subsequent stenosis is averted.
SUMMARY
Auricular, preauricular, and postauricular flaps, compared to skin grafts, provide a more permanent solution
for stenosis of the external auditory meatus.

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FIGURE 91.2 A: Outline of the preauricular skin flap. B: Preauricular skin flap in place. (Continued)
FIGURE 91.2 Continued. C: Preoperative stenosis of the auditory canal. D: Postoperative result following
release of the meatal stenosis with a preauricular skin flap. (From Macomber, ref. 4, with permission.)
References
1. Owens N. An effective method for closing defects of the external auditory canal. Plast Reconstr Surg
1959;23:381.
2. Renard A. Postauricular flap based on dermal pedicle for ear reconstruction. Plast Reconstr Surg
1981;68:159.
3. Songcharoen S, Smith RA, Jabaley M. Tumors of the external ear and reconstruction of defects. Clin Plast
Surg 1978;5:447.
4. Macomber WB. Reconstruction of the traumatically stenosed external auditory canal. Plast Reconstr Surg
1958;22:168.

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Chapter 92
Skin Flap to The Torn Earlobe
A. M. PARDUE
EDITORIAL COMMENT
Creating an immediate ear ring opening as one corrects a congenital or split ear lobe is done rarely. It is
preferable to pierce a new hole secondarily, usually away from the linear suture line.
The earliest known reference to a flap concerned the repair of cleft earlobes (1). Cleft earlobe deformity may be
congenital or acquired (2, 3, 4). Acquired cleft earlobe may be complete or incomplete (3, 5).
INDICATIONS
Repair of congenital cleft earlobe consists of excising the skin of the opposing surfaces of the cleft and
approximating the two sides with or without a small Z-plasty within the suture line as it curves around the
earlobe (1, 3, 6). Acquired cleft of the earlobe is usually due to a tear through the lobe by a sudden pull on
an earring or by prolonged pull of a heavy earring.
Here we are primarily concerned with a repair of a complete or incomplete cleft of the earlobe with
preservation of an earring opening that is correctly positioned. If the cleft is incomplete, the bridging tissue
should be excised, creating a complete cleft, to avoid bulging of the bridging tissue (3).
ANATOMY
The repair of a cleft earlobe with preservation of the earring opening consists of raising a small transposition flap
whose
blood supply is derived from the ample vascularity of the earlobe and the rich plexus of vessels in the skin and
subdermal areas (5).

FIGURE 92.1 A: The shaded areas show the opposing surfaces of the cleft to be excised. B: The skin has been
excised, and the back-cut for the transposition flap is shown. C: The small flap is transposed to the opposite side
and sutured. D: The cleft is closed in a straight line.
FLAP DESIGN AND DIMENSIONS
The flap is based superiorly to one side of the upper end of the cleft. The width of the flap is the width of the
inner surface of the cleft near its superior end. The flap is approximately 3 mm long and 1 mm thick.
OPERATIVE TECHNIQUE
The procedure starts with outlining the flap and the area to be excised (Fig. 92.1A). The margins of the cleft are
excised, and a small flap is raised on one side at the upper end of the cleft (Fig. 92.1B). The distal edge of the
flap is sutured to the opposite side so that the suture line is not at the dependent area of the perforation (Fig.
92.1C). The raw surfaces of the cleft are approximated with two to three sutures of 5-0 Vicryl, and the skin
margins are closed with 6-0 Prolene (Fig. 92.1D). A Z-plasty may be used to interrupt the suture line on the curve
of the earlobe. A single loop of 4-0 clear nylon suture is left within the perforation for 4 to 6 weeks and then is
replaced with an earring. The technique is simple and is readily done with the patient under local anesthesia
(Fig. 92.2).
FIGURE 92.2 A: Preoperative view showing an incomplete cleft. B: Postoperative view showing the repaired
cleft with the loop of clear nylon passing through the perforation.

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A different technique (7) using a posterior transposition flap has been reported, but the design of this flap
requires excising more normal skin from one side of the cleft, with possible distortion of the flap as it is
transposed and twisted into the perforation canal.
CLINICAL RESULTS
Results with this technique have been uniformly good for both complete and incomplete clefts. There have
been no reports of failures of the flap. The patient should be instructed not to wear heavy earrings again or
ones that might be snagged easily, thereby retearing the earlobe.
SUMMARY
A skin flap can be designed from the margin of a torn earlobe to correct the deformity and at the same time
provide a skin-lined canal for a new earring opening.
References
1. McDowell F. Sushruta's ancient earlobe and rhinoplastic operations in India (Editorial comment on classic
reprint). Plast Reconstr Surg 1969; 43:517.
2. Yamada A. The evaluation of the cleft earlobe. Jpn J Plast Reconstr Surg 1976;19:171.
3. Boo-Chai K. The cleft earlobe. Plast Reconstr Surg 1961;28:681.
4. Dibbell DG. Split earlobe deformities. Plast Reconstr Surg 1970;45:77.
5. Pardue AM. Repair of torn earlobe with preservation of the perforation for an earring. Plast Reconstr Surg
1973;51:472.
6. Hamilton R, LaRossa D. Method for repair of cleft earlobes. Plast Reconstr Surg 1975;55:99.
7. Buchan NG. The cleft earlobe: A method of repair with preservation of the earring canal. Br J Plast Surg
1975;28:296.

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Chapter 93
Repair of The Cleft E Arlobe With An Advancement Flap and Two
Unilateral Z-Plasties
B. STRAUCH
M. KEYES-FORD
EDITORIAL COMMENT
This is an excellent technique to avoid secondary notching and indentation of a traumatic laceration of the
lobule of the ear. The combination of a sliding advancement flap with Z-plasties gives a rounded
appearance to the earlobe and lengthens the surgical scar.
Many flaps have been described for repair of the cleft earlobe (1, 2, 3, 4, 5, 6, 7, 8). Our preferred technique
uses an advancement flap with two unilateral Z-plasties.
INDICATIONS
This procedure allows repair of the cleft, and retention of the normal curve of the earlobe, as well as
preventing late notching.
ANATOMY
The transposed flaps created by the advancement flap and Z-plasties are supplied by a rich plexus of perforators
from both the superficial temporal and posterior auricular arteries, which are branches of the external carotid.
Venous drainage is from the accompanying veins (9).
FLAP DESIGN AND DIMENSIONS
The procedure is designed so that an advancement flap from the posterior limb of the cleft provides the rounded
contour of the lower edge of the lobule. Two unequal, unilateral Z-plasties are transposed in a superior direction.
An incision on the posterior limb of the cleft bisects this limb, using the lower third as the advancement flap (A-B),
and the upper two thirds (B-C-E') becomes the lower unilateral Z-plasty. An incision (D-C') on the anterior limb of
the cleft creates the second unilateral Z-plasty (see Fig. 93.1, D-C'). The inferior border of the anterior limb of the
cleft is deepithelialized to accept the advancement flap (see Fig. 93.1, B' -A').
OPERATIVE TECHNIQUE
First, markings similar to those in Figure 93.1 are made on the anterior and posterior limbs. The healed edges of
the cleft are excised. The lower edge of the anterior limb is excised to the subcutaneous level (Fig. 93.2, B' -A').
The incision at the lower edge of the posterior limb is incised to create an advancement flap that corresponds to
the length of the deepithelialized portion of the anterior limb (see Fig. 93.2, A-B). The two unilateral Z-plasties
are created by making incisions into the anterior and posterior limbs, as previously mentioned (see Fig. 93.2, E' -
C-B, C' -D-E').
All flaps are transposed by starting with the lower advancement flap (A-A'). Flap E-C-B is transposed into the

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defect D-C' created in the anterior limb of the cleft. Flap C'-D-E is transposed into the defect E'-D' created in the
posterior limb. If point E is in excess, it may bulge and should be trimmed or, alternatively, a relaxing incision can
be made in the apex of the cleft to allow point E to lie flat (Fig. 93.3). The lateral surface suture line of the
earlobe is sutured with 6-0 nylon, the medial surface with 5-0 nylon.
CLINICAL RESULTS
Good results using this technique can be obtained with complete as well as incomplete cleft earlobes.
(Incomplete
clefts should be converted into complete ones.) Once the incisions have healed, a rounded contour at the
lower rim of the earlobe is formed, without notching. Patients can have the ear pierced in approximately 6
months or when the suture line has softened. They are discouraged from wearing heavy, hanging earrings
that can recreate the same deformity.
FIGURE 93.1 Diagram of plan of proposed flaps. (From Strauch, Keyes-Ford, ref. 8, with permission.)

FIGURE 93.2 Diagram of flap incisions. (From Strauch, Keyes-Ford, ref. 8, with permission.)
FIGURE 93.3 Diagram of flap transpositions. (From Strauch, Keyes-Ford, ref. 8, with permission.)
SUMMARY
An advancement flap and two unilateral Z-plasties provide a simple solution for the repair of the cleft
earlobe, by creating a smooth, round contour at the lower edge and by preventing recurrent notching.
References
1. Argamaso RV. The lap joint principle in the repair of cleft earlobe. Br J Plast Surg 1978;31:337.
2. Buchan BG. The cleft earlobe: A method of repair with preservation of the earring canal. Br J Plast Surg

1975;28:296.
3. Hamilton R, Donato L. Method for repair of cleft earlobes. Plast Reconstr Surg 1975;55:99.
4. Khoo Boo-Chai MD. The cleft earlobe. Plast Reconstr Surg 1961;28:681.
5. Pardue AM. Repair of the torn earlobe with preservation of the perforation for an earring. Plast Reconstr
Surg 1973;51:475.
6. Dibbell DG. Split earlobe deformities. Plast Reconstr Surg 1970;45:77.
7. McLaren L. Cleft earlobes: A hazard of wearing earrings. Br J Plast Surg 1954;7:102.
8. Strauch B, Keyes-Ford M. Repair of the cleft earlobe with an advancement flap and two unilateral z-
plasties. Plast Reconstr Surg 1997;99: 1074.
9. Cormack GC, Laberty BG. The arterial anatomy of skin flaps. Edinburgh: Churchill Livingstone, 1986;116-
121.

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Chapter 94
Roll-Under (Or Fold-Under) Flap for Release of Earlobe
Contractures
J. R. LEWIS JR.
EDITORIAL COMMENT
As pointed out by the author, this technique is also applicable to secondary face lifts where there has been
a downward pull and distortion of the earlobe.
The roll-under (or fold-under) flap for rounding of a contracted earlobe has been very useful in this author's
experience, particularly in secondary face-lifts. When the original face-lift has been performed and it pulls down
on the earlobe, a tight, tapered lobe often follows. It is unsightly and makes difficult a secondary meloplasty
without an obvious scar below the lobe. Some lobes are naturally tapered, and these can be rounded as well,
both to simplify wearing earrings and to hide the scar at the junction of lobe to cheek.
INDICATIONS
The procedure is probably used in one patient of four in whom the author performs a meloplasty, either to
avoid tapering the borderline lobe or to correct a lobe that is already tapered or contracted. Obviously, the
need for performing this as a secondary procedure will be decreased greatly by care in the original surgery
to give adequate support to the anterior and posterior flaps at a higher level, so that no pull is carried to the
earlobe itself.

FIGURE 94.1 A,A': Outline of flap, rectangular in shape, below and slightly behind the ear and based on
the lobe itself. B,B': Roll-under (or fold-under) of the flap medially and upward to round the earlobe. In
isolated lobe reconstruction, the donor defect may be closed as a simple linear closure below the earlobe
and slightly behind the angle of the jaw. C,C': Use of the roll-under flap to round the earlobe along with a
meloplasty. Note that the incision was carried upward in front of the ear and upward behind the ear,
bringing the cheek and neck tissues upward to close the defect against the newly rounded lobe rather than
closing a donor defect below the lobe. Obviously, the incisions would extend farther superiorly with the
usual meloplasty.
ANATOMY
The circulation comes from small branches of the superficial temporal artery to the anterior aspect of the ear and
from the posterior auricular vessels that supply the superficial aspects of the ear and the earlobe. There should
be no problems with circulation if the flap is not overly and unnecessarily thinned.
FLAP DESIGN AND DIMENSIONS

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The roll-under flap is a relatively broad-based flap, with the length of the flap generally no longer than its width.
The flap has a thick base because it is not thinned except in its terminal end for fitting into the V resection (Fig.
94.1).
The incision is outlined by a skin pencil at the time of meloplasty, or the correction may be of an earlobe alone. It
is necessary to carry the incision upward in front of the ear to about the tragus and posterior to the ear for about
the same distance to slide the skin anteriorly and posteriorly upward to avoid additional pull on the lobe once the
rounding has been accomplished (see Fig. 94.1).
Generally, it is not difficult to correct this during a meloplasty or as an earlobe correction alone because the
tissue along the jawline usually will give enough for adequate correction, even when it has been pulled tightly or
has been scarred by the previous surgery. In such cases, however, the flap may be outlined more posteriorly.
With overly tight closure and overzealous skin resection, the earlobe is usually pulled not only downward but
anteriorly. Correction of the positioning and of the rounding of the lobe is therefore accomplished simultaneously.
OPERATIVE TECHNIQUE
A number of methods for correcting this problem have been devised, but for about 25 years, the author has used
the following simple technique. A small skin flap based on the lobe is outlined along the jawline below the
earlobe and rolled (or folded) up under the lobe to separate the lobe from the cheek. The jawline defect is small
and is corrected by simply pulling the cheek upward in front of the ear and upward and backward behind the ear
as in a face-lift procedure. Deep support of the cheek tissue is carried upward anteriorly to the temporal scalp
and to the deep fascia of the cheeks in front of the ear, and posterior to the ear it is carried to the mastoid fascia
and the occipital scalp. Thus, there is no residual pull on the earlobe.
CLINICAL RESULTS
The success rate of correction of earlobe deformities by this simple method has been high. Because of the
give in the tissues over a period of months or years following the meloplasty, adequate support is generally
achieved posteriorly and anteriorly, and the lobe is adequately rounded to allow for this. On occasion, the
earlobe may be left a little too redundant, but this is considered in planning the procedure.
When the lobe is naturally too redundant already, a similar procedure may be used to reduce the length or
width of the lobe by additional vertical resections within
the lobe and horizontal resection of the lobe itself rather than by creating the skin flap below the lobe.
Reduction of the earlobe is beyond the scope of this chapter, but it may be carried out along with the
rounding and correction of contractures.
SUMMARY
The roll-under (or fold-under) flap has proved quite effective over the years for rounding of a contracted
earlobe.

Chapter 95
Lateral Neck Skin Flap for Earlobe Reconstruction
S. ZENTENO ALANIS
The author has developed a technique for earlobe reconstruction that creates a normal-appearing lobe (1, 2, 3).
FLAP DESIGN AND DIMENSIONS
The size and shape of the opposite earlobe are used as the model for the earlobe being reconstructed. The flap
design is shown in Figure 95.1. A line is drawn from point A (site of earlobe implantation) to point B (the most
inferior point of the lobe) and from point A to point C (the most posterior point of the transverse diameter of the
lobe). From points B and C, a vertical flap is traced downward, perpendicular to the line AC. Line BD should be
equal in length to line AB and line CD to line CA. The flap should be made 1 to 2 mm larger than desired to
compensate for retraction of the tissue after it is incised. The incisions will follow the line ABDC.
FIGURE 95.1 The various steps for earlobe reconstruction (see text).
OPERATIVE TECHNIQUE
The earlobe reconstruction may be achieved in one surgical procedure with the patient under local anesthesia
(Fig. 95.2). The skin from the adjacent lateral neck is used because it possesses characteristics similar to
earlobe skin. The flap is dissected to include the subcutaneous tissue, and it is detached up to the projection of
the line AC (Figs. 95.1 and 95.3B). Following this, the tip D of the flap is taken to point A, where it is fixed by a
transfixion suture (Figs. 95.1 and 95.2C). The flap BDC is placed in such a way that it will provide the posterior
cover of the earlobe by suturing the edge BD to BA with 5-0 or 6-0 nylon. Interrupted sutures fix the posterior
edge of the flap (line CD) to the depth of the projected line ( AC).
The donor area of the flap is closed directly after the necessary undermining of the skin edges. It is closed in two
directions with interrupted sutures. The resulting scar ABD will be partially hidden by the reconstructed earlobe
(Figs. 95.1 and 95.2C).

FIGURE 95.2 A: Congenital absence of the earlobe and a cup deformity of the ear. B: Intraoperative view with
flap elevated. C: The reconstructed ear after a one-stage procedure using the described technique for earlobe
reconstruction.
FIGURE 95.3 A: Traumatic loss of part of the ear, including the earlobe. A costal cartilage graft and local skin
flap have already been used to create a new upper pole of the ear. B: Final appearance after retroauricular skin
grafting.
CLINICAL RESULTS
This technique of earlobe reconstruction has been used in 13 patients (11 males and 2 females) with very
good results. The advantages are that it may be done in one surgical procedure with the patient under local
anesthesia. The tissues used are similar to the normal lobe; there are no changes in pigmentation; and
tissue thickness and consistency are appropriate. The donor area is closed by wound edge approximation.
SUMMARY
The earlobe can be reconstructed from neck skin just inferior and posterior to the missing lobe.

References
1. Subba Rao YV, Venkateswara Rao P. A quick technique for earlobe reconstruction. Plast Reconstr Surg
1968;41:13.
2. Karkas LG, Dobisikova M, Hajnis K. Pautas para determinar el período de las corrections quirúrgicas de
anomalías innatas del pabellón de la oreja exceptuando la aplasia. Rev Gat Am Cirug Plast 1966;10:82.
3. Zenteno Alanis S. Reconstructión en pérdidas parciales del pabellón auricular. Trib Med Mex 1975;29:A3.