Operative Technique in Plastic Surgery – Kevin C.Chung

Graft
■ The procedure can be performed under general or local anesthesia,
depending on size of the wound, general medical condition, and patient
preference.
■ Nerve blocks can enhance patient comfort.
■ The cheek can be anesthetized by injecting the infraorbital,
zygomaticofacial, and mandibular branch of trigeminal (V3) nerves.2
■ The entire face and neck are prepped with a povidone-iodine solution and
draped.
■ This wide exposure allows visualization of both sides of the face to check
for symmetry and gives access to all donor sites.
■ The wound bed is prepared.
■ If there is fibrinous material in the wound, it is cleaned down to healthy
tissue (TECH FIG 1A). One simple way of doing this is by rubbing a dry
piece of gauze in the wound, which will remove loose fibrinous material
and nonviable debris.
■ A water-based device (eg, Versajet) can be used for more aggressive yet
controlled debridement. For thick eschars (eg, burn wounds), a scalpel or
Weck blade is used.
■ A template of the defect is made with a sterile glove wrapper. An easy way
to do this is to press the wrapper against the wound. The blood will stain the
wrapper and outline the defect. This can then be cut with scissors and tailored
to the shape of the defect.
■ An appropriate donor site is then chosen. Donor sites within the face and
neck have a better color match compared to more distal sites.
■ The template is oriented on the donor site and marked (TECH FIG 1B).
■ Local anesthetic (0.25% bupivacaine with epinephrine) is infiltrated.
■ The skin graft is harvested full thickness using a knife.
■ The donor site is closed. Undermining of the edges can be done to help the
closure.
■ The skin graft is defatted on the back table.
■ This is performed by stretching out the graft using hemostats at four edges
of the graft and placing of the nondominant finger.
■ A very thin layer of fat may be left in select cases with optimum recipient
beds and can improve outcomes. This thin fat layer supports gliding of the

graft and may enable future revision with fat grafts to correct contour
deformities if they arise.
■ Care should be taken to avoid overthinning of grafts with removal of a
portion of the dermis (in effect creating a split-thickness graft), as this will
result in graft contracture and poor aesthetic outcomes.
■ The graft may be pie crusted in a few small areas by making small slits with
a no. 11 knife.
■ This allows egress of fluid during the initial few days when graft adherence
to the wound bed is critical. This is not critical in all cases.
■ The skin graft is then inset on the wound.
■ It is tacked in a few corners with 50 chromic sutures to anchor the graft
(TECH FIG 1C).
■ Remainder of the skin graft can be sutured with a running technique. We
often use 6-0 fast-absorbing gut sutures; however, nylon sutures may also
be used.
■ A bolster dressing is created with Xeroform gauze or cotton balls soaked in
mineral oil to fashion a tie over bolster (TECH FIG 1D).

TECH FIG 1 • A. Cheek defect after resection with
negative margins. B. Full-thickness skin graft marked
in the infraclavicular area. C. Full-thickness graft has
been sutured in place and Frost sutures placed to
support the lower eyelid. D. Bolster dressing sutured
in place.
■ Cheek Reconstruction With Split-Thickness Skin
Graft
■ Split-thickness skin grafts are useful in patients in whom a full-thickness
skin graft is not available or there are contraindications for full-thickness
graft harvest (eg, massive burns, inadequate donor sites, medical
contraindications).
■ The face and neck are prepped and draped as above. The wound bed is

prepared.
■ A template of the wound is made. This is used to mark the donor site.
■ Split-thickness skin grafts can be harvested from any available donor site in
the body.
■ Commonly they are harvested from the thighs due to easy accessibility.
■ Split-thickness skin grafts harvested from the scalp provide a better color
match.
■ The donor site is injected with 0.25% bupivacaine with epinephrine for pain
control and hemostasis.
■ The skin graft is harvested with a dermatome at a thickness of 0.012 to 0.014
inches.
■ The donor site is then covered with an epinephrine-soaked gauze pad for
hemostasis.
■ Split-thickness skin grafts in the face are used as sheet grafts and are not
meshed. Meshed grafts on the face are cosmetically unacceptable.
■ The graft is pie crusted by making small slits with a knife. This allows
egress of fluid during the initial few days when graft adherence to the
wound bed is critical.
■ The skin graft is then inset on the wound.
■ It is tacked in a few corners with 50 chromic sutures to anchor the graft.
■ Remainder of the skin graft can be sutured with a running suture. We often
use 6-0 fast absorbing gut sutures; however, nylon sutures may also be
used.
■ A bolster dressing is created with Xeroform gauze or cotton balls soaked in
mineral oil to fashion a tie over bolster.
■ The donor site is dressed with alginate dressing and covered with a
transparent membrane dressing (Opsite).
PEARLS AND PITFALLS
Graft
thickness
■ Full-thickness skin grafts are preferred for facial reconstruction.
They have a better color, contour, and thickness match compared
to split-thickness skin grafts.
■ If split-thickness grafts are used, they should not be meshed if at

all possible as this results in a cosmetically unacceptable
appearance.
Wound bed
■ The wound bed should be well vascularized. It should be debrided
to remove any fibrin or nonviable tissue that will impede graft
take.
■ Hemostasis should be assured because blood under the skin graft
will prevent graft adherence.
Donor site
■ Skin graft donor sites from the face and neck will have the best
color match. Donor sites caudal to the clavicles have poor match.
■ A template of the defect should be created. This helps to
accurately plan the skin graft harvest.
Appearance
■ Skin grafts may have a patchlike appearance. This is due to the
difference in color, texture, and thickness between the donor and
recipient sites (FIG 3). This becomes more obvious with sun
exposure as the untanned skin grafted area becomes more visible
compared to the tanned native skin.
■ Patch appearance can be minimized by selecting donor sites with a
color match as close as possible to the defect (FIG 4).
■ Minimal thinning of the graft (and preservation of a thin layer of
subcutaneous fat) improves the long-term appearance of the graft
(FIG 5).
Postoperative
care
■ Any fluid collections under the skin graft should be promptly
evacuated with a needle or knife blade.
■ Infections can result in graft loss and should be treated early.
Revisions
■ Procedures like dermabrasion, laser, and dermal fat grafts can
improve the final aesthetic result.
POSTOPERATIVE CARE
■ The skin graft and bolster are kept dry and protected from trauma.
■ The bolster is removed 5 to 8 days postoperatively.
■ If there is any accumulation of fluid under the skin graft, it is evacuated with
a needle or small scalpel nick.
■ A thin layer of petrolatum jelly (Vaseline) is applied twice a day for
approximately 3 weeks.
■ Full-thickness skin grafts: The donor site can be washed in 24 hours.
■ Split-thickness skin grafts: If the alginate dressing gets soaked, it can be
changed in 24 to 48 hours. Otherwise, it is changed at the time of bolster
removal.

OUTCOMES
■ Dermabrasion can improve the appearance of skin grafts.3
■ This is done several months postoperatively, once the skin graft has
completely healed. This helps smooth areas of contour irregularities.
FIG 3 • A. Split-thickness skin graft was used to treat a
large cheek defect of an obese man with multiple
medical comorbidities. B. 1 year postoperatively. C.
Note shrinkage of graft with time and new biopsy site
with dressing.
■ Patients with large skin grafts or those at high risk for hypertrophic scar
formation can be treated with facial pressure garments.4 Silicone sheeting can
also be helpful.
■ There is some evidence, however, that pressure garments may cause
disturbance of facial growth in children.5
■ Laser therapy has been shown to help improve the appearance of facial scars.6
■ Pulse dye lasers can be used to improve the appearance of hypertrophic and
erythematous skin grafts.
■ Contour depressions that are unsightly can be improved with dermal fat
grafts.7
■ This is done at least 6 months postoperatively or even longer if graft scar
maturation has not occurred.
■ These grafts can be harvested from any part of the body, commonly around a
pre-existing scar or the lower abdomen.

■ The dermal fat grafts are contoured to the deformity and placed under the
skin graft.
COMPLICATIONS
■ Complete or partial skin graft loss can occur due to a blood or fluid collection
under the graft or movement of the graft preventing graft adherence.
■ Hemostasis at the wound bed should be assured prior to placement of skin
graft.
■ The graft should be bolstered securely to prevent graft movement.
■ Infections can occur at the graft or donor site.
■ Graft site infections can result in sloughing of the skin graft. Patients at risk
are diabetics, immunocompromised, and smokers.
■ Infections should be treated early with antibiotics.
■ Secondary contracture of the graft can result in contour abnormalities and
distortion of adjacent structures.
■ Grafts close to the lower eyelid can result in cicatricial ectropion.
FIG 4 • A,B. This cheek defect was allowed to fill in by

granulation tissue over a 3-week period, and a full-
thickness skin graft was harvested from the cervical
area. C,D. Excellent contour and acceptable skin color
match are seen postoperatively.
FIG 5 • A,B. Large defect in the upper cheek and lower
eyelid area. A full-thickness skin graft was harvested
from the upper chest area and thinned minimally after
allowing the area to granulate and fill in for 2.5 weeks.
C,D. Excellent contour and lack of graft shrinkage are
seen postoperatively.
REFERENCES
1. Zide B, Longaker M. Cheek surface reconstruction: best choices according to
zones. Oper Tech Plast Reconstr Surg. 1998;5:26.
2. Zide BM, Swift R. How to block and tackle the face. Plast Reconstr Surg.
1998;101(3):840-851.
3. Robinson JK. Improvement of the appearance of full-thickness skin grafts

with dermabrasion. Arch Dermatol. 1987;123(10):1340-1345.
4. Coeugniet E, Martinot-Duquennoy V, Gottrand L, et al. Early preventive
pressure therapy in extensive skin grafts on children’s face, a comeback of
classic methods? A retrospective study on 8 cases. Ann Chir Plast Esthet.
2007;52(6):561-568.
5. Fricke NB, Omnell ML, Dutcher KD, et al. Skeletal and dental disturbances
after facial burns and pressure garments. J Burn Care Rehabil. 1996;17(4):338-
345.
6. Sawcer D, Lee HR, Lowe NJ. Lasers and adjunctive treatments for facial
scars: a review. J Cutan Laser Ther. 1999;1(2):77-85.
7. Davis RE, Guida RA, Cook TA. Autologous free dermal fat graft:
reconstruction of facial contour defects. Arch Otolaryngol Head Neck Surg.
1995;121(1):95-100.

29
CHAPTER
Section IX: Ear
Antia-Buch Flaps for Ear
Reconstruction
Amir M. Ghaznavi and Brian R. Gastman
DEFINITION
■ Antia-Buch flaps are best used for traumatic or postsurgical helical defects of
the upper third and middle third of the ear that measure between 25% and 50%
of length of the helix.1
ANATOMY
■ The ear is made up of delicate skin and soft tissues covering a cartilaginous
framework and underlying muscles.
■ The cartilaginous portion of the ear includes the conchal bowl, antihelix, and
helix.
■ The surrounding muscles of the ear can be divided into intrinsic muscles
(muscles that originate and insert on the ear) and extrinsic muscles (muscles
that originate in other regions of the skull and insert onto the ear).
■ The intrinsic muscles include the helicis major, helicis minor, tragicus,
antitragicus, transverse, and oblique muscles.
■ The extrinsic muscles include the anterior, superior, and posterior auricular
muscles.
■ The arterial supply of the ear is derived from the posterior auricular artery and
perforators arising from the superficial temporal artery.
■ Venous drainage is provided by the posterior auricular veins that drain into the
external jugular system as well as the superficial temporal and retromandibular
veins.
■ Lymphatic drainage of the ear is to the parotid, infraclavicular, mastoid, and

infraauricular cervical nodes.
■ Sensory innervation of the ear is provided by:
1. Great auricular nerve (C2–C3)
• Auriculotemporal nerve (V3)
• Lesser occipital nerve
• Auricular branch of the vagus nerve (Arnold nerve)
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A complete history and physical exam of the head and neck should be
performed to document the exact location of the defect within the ear (superior
third, middle third, and lower third portions) and involvement of cartilage if
present.
■ The patient should also be examined for evidence of nodal metastases and
secondary lesions in the head and neck region. Attention should be paid to the
lymph node basins in the parotid and cervical areas.
■ Comorbidities that can increase the risk of postoperative wound healing and
bleeding complications should be evaluated and optimized if possible.
IMAGING
■ No imaging is required for Antia-Buch flaps; however, imaging of the head
and neck region may be necessary to evaluate tumor metastasis.
NONOPERATIVE MANAGEMENT
■ Isolated skin defects of the helical rim with intact underlying cartilage and
perichondrium can heal by secondary intention or full-thickness skin grafting.
■ Full-thickness skin grafts can result in excellent outcomes in patients with
preserved cartilaginous support. However, healing by secondary intention or
skin grafting of more complex lesions that include full-thickness excision of
the underlying cartilage may result in contour abnormalities and require more
complex reconstructions.
SURGICAL MANAGEMENT
Preoperative Planning
■ The contours of the ear are marked preferably before skin prep to avoid
washing off.
■ Patients who have large defects of the ear should be counseled that they may
require contralateral reduction by wedge resection and/or setback of the

unaffected ear at a later time to obtain symmetry.
Positioning
■ The patient is placed in a supine position with the entire ear exposed including
the hairline.
■ The bed is turned 180 degrees to allow unimpeded approach to the head and
neck area.
■ The contralateral ear may be exposed if planning on contralateral procedure
and to evaluate symmetry.
Approach
■ Several surgical approaches have been described for Antia-Buch flaps
including those for “classic” helix-only defects that are less than 25% of the
total length of the helix, as well as modifications for longer defects and defects
that include loss of the helix, scapha, and antihelix.
■ Prophylactic antibiotics are administered by most surgeons particularly if the
cartilage or perichondrium has been removed.
■ Coverage with fluoroquinolones provides excellent cartilage penetration and
provides coverage of common organisms that can cause infections of the ear
(eg, Pseudomonas aeruginosa).
■ Prolonged antibiotic treatment is usually not necessary unless the wound is
contaminated or the patient is otherwise at risk for postoperative infections.
T E C H N I Q U E S
■ “Classic” Helix-Only Defect1
■ The lesion and the proposed area of resection are identified and marked on
the ear (TECH FIG 1A).
■ The resection is performed with an incision in the helical sulcus to remove
the lesion and separate the helical cartilage from the scapha (TECH FIG
1B).
■ An incision is made in the helical sulcus (either inferiorly, superiorly, or
both) extending through the anterior skin and cartilage taking care to avoid
injury to the postauricular skin.

■ The posterior skin is undermined superficial to the perichondrium to the
level of the auricular cephalic sulcus, resulting in formation of a
chondrocutaneous composite flap based on the posterior skin (TECH FIG
1C).
■ If the defect is small (less than 10%), the inferior segment can be advanced,
and the redundant Burrow triangle can be excised if necessary.
■ For intermediate defects (10%–25%), both the superior and inferior portions
need to be advanced for a tension-free closure (TECH FIG 1D).
TECH FIG 1 • A. Helix defect marked. B. Helix freed
from scapha. C. Formation of chondrocutaneous
composite flaps superior and inferior. D. Composite
flaps advanced and closed.
■ Modification for Defects of More Than 25% of the
Helix1,2
■ Defects that are more than 25% of the total length of the helix may require a
modification of the classic technique of closing the defect without tension.
■ The superior and inferior incisions are performed as described above to
elevate the chondrocutaneous composite flaps.
■ Additional mobilization of the superior segment is obtained by performing a
V-Y advancement flap of the root of the helix, thereby extending the reach of
the superior flap (TECH FIG 2).
■ If additional mobilization is necessary to avoid cupping of the ear or to
obtain a tension-free closure, then the advancement of the superior flap can
be increased with a wedge resection of the scaphal cartilage.

■ Alternatively, the superior part of the scapha can be trimmed by a few
millimeters to decrease the distance that the superior flap must advance.
■ However, this modification will result in shortening the height of the ear.
TECH FIG 2 • A. Making a V cut into the root of the
helix. B. Advancement of superior segments.
■ Modification for Defects Including the Helix and
Scapha3
■ In some cases, resection of tumors or traumatic lesions results in loss of the
helix and a portion of the scapha.
■ A modification of the Antia-Buch flap can be performed by excising a
crescent-shape portion of the anterior chondrocutaneous tissues on either side
of the defect (TECH FIG 3A).
■ The superior and inferior segments are then advanced using the classic
approach (with or without the helical root V-Y advancement flap) to close the
resulting defect (TECH FIG 3B,C).

TECH FIG 3 • A. Helical-scaphal defect. B. Helical-
scaphal defect with excision of the chondrocutaneous
anterior tissue. C. Advancement of segments.
■ Modification (C) for Helix, Scapha, and
Antihelix4,5
■ Resections of the ear that include the helix, scapha, and antihelix can also be
closed with modification of the classic Antia-Buch flaps.
■ In these cases, wedge excisions of anterior cartilage and skin of the superior
and inferior poles of the concha are performed (TECH FIG 4A).
■ A paring incision in the concha is performed to allow tension-free
advancement of the superior and inferior segments (TECH FIG 4B).
■ The superior and inferior segments are then advanced for wound closure
(TECH FIG 4C).

TECH FIG 4 • A. Helical-scaphal-antihelix defect. B.
Paring incision in the concha and wedge resections.
C. Advancement of segments.
PEARLS AND PITFALLS
Hemostasis
■ Meticulous hemostasis must be obtained.
Anesthetic
■ Avoid any epinephrine on anterior aspect of pinna to avoid
possibility of skin necrosis.
Surgical
technique
■ Care must be taken to avoid injury to the postauricular skin flap as it
is the blood supply to the chondrocutaneous flaps.
■ The dissection should be performed superficial to the perichondrium.
POSTOPERATIVE CARE
■ A noncompressive dressing can be applied for comfort.
■ Topical antibiotic ointment can also be applied at the discretion of the surgeon
once the dressing is removed.
■ No postprocedure prophylaxis is required in most cases.
■ Sutures are typically removed in 7 to 10 days.

■ The patient should be advised to avoid pressure on the operated ear and should
refrain from sleeping on the affected side.
■ Patients who wear glasses should be advised to avoid wearing glasses or
remove the stem from the affected side until healing has occurred.
■ Patients should also avoid applying ice to the area postoperatively.
OUTCOMES
■ Ramsey et al. reported 47 patients with chondrocutaneous helical rim
advancement flaps of Antia and Buch. Indications were helical rim defects of
25% to 50%.6
■ No necrosis was reported.
■ Two patients had hematomas.
■ Superior cosmetic results
■ Noel et al. reviewed 15 retrospective patients after modified chondrocutaneous
helical rim advancement flaps.7
■ 2.5 cm mean defect size
■ Upper flap changed to transposition flap rather than advancement flap thus
eliminating resection of scapha
■ No skin necrosis or hematoma
COMPLICATIONS
■ Skin necrosis is a rare complication but may occur in smokers or patients who
have untreated hematomas.
■ It is generally managed conservatively if the area is clean but may require
debridement and grafting or other reconstructive procedures for extensive
skin/cartilage loss.
■ Ear hematoma is more common and can be problematic if it is not managed
expeditiously.
■ Hematoma may cause cartilage growth/deposition (so-called cauliflower
deformity) and may be very difficult to manage in a delayed setting.
■ Large hematomas may cause skin and cartilage necrosis and infections.
Hematomas should be drained either with a needle or more commonly by
reopening the incision. Drains are rarely necessary.
■ Infections are rare. Most respond quickly to oral antibiotics; however, more
severe cases may require intravenous antibiotics and/or incision and drainage
as necessary.

■ Long-term edema is also uncommon but can be problematic when it occurs.
Although the etiology of this is not known, this complication is likely related to
impaired lymphatic drainage.
■ Lymphatic massage and compression dressings may be helpful in these
instances.
■ Cancer recurrence and other causes of swelling should also be ruled out.
REFERENCES
1. Antia NH, Buch VI. Chondrocutaneous advancement flap for the marginal
defect of the ear. Plast Reconstr Surg. 1967;39:472-477.
2. Brent B. The acquired auricular deformity: a systematic approach to its
analysis and reconstruction. Plast Reconstr Surg. 1977;59:475-485.
3. Low DW. Modified chondrocutaneous advancement flap for ear
reconstruction. Plast Reconstr Surg. 1998;102;174-177.
4. Bialostocki A, Tan ST. Modified Antia-Buch repair for full-thickness upper
pole auricular defects. Plast Reconstr Surg. 1999;103(5);1476-1479.
5. Fata JJ. Composite chondrocutaneous advancement flap: a technique for the
reconstruction of marginal defects of the ear. Plast Reconstr Surg.
1997;99:1172-1175.
6. Ramsey ML, Marks VJ, Klingensmith MR. The chondrocutaneous helical rim
advancement flap of Antia and Buch. Dermatol Surg. 1995;21:970-974.
7. Noel W, Leyder P, Quilichini J. Modified Antia-Buch flap for the
reconstruction of helical rim defects. J Plast Reconstr Aesthet Surg.
2014;67:1659-1662.

30
CHAPTER
Postauricular Flap for Ear
Reconstruction
Matthew M. Hanasono
DEFINITION
■ Reconstruction of auricular defects arising from trauma or oncologic resection
aims to restore the natural anatomic structures and landmarks of the ear and
ideally should maintain balance and symmetry with the contralateral ear.
■ Postauricular flaps are useful for reconstructing larger marginal defects of the
upper and middle thirds of the auricle and are typically used in combination
with cartilage grafts for reconstructing those defects that are too large for
wedge or Antia-Buch chondrocutaneous advancement techniques.1
■ The postauricular flap is also known as the retroauricular flap or the
Dieffenbach flap.
■ Inferiorly based postauricular flaps can also be used for ear lobe reconstruction
(see chapter on Reconstruction of the Ear Lobe).
ANATOMY
■ The outer rim or helix creates the outer curvature of the ear and originates
from the face at the root of the helix.
■ Concentrically, within the helix is the antihelix, which separates into two
separate crura in the upper third of the ear that define the triangular fossa.
■ The scapha is the concave rim that separates the helix and antihelix.
■ The concha lies within the antihelix and is the structure that leads to the
external auditory meatus.
■ The anterior border of the external auditory meatus is defined by the tragus.
■ In the lower third of the ear lies the lobule or ear lobe, which does not
contain cartilage (FIG 1A).
■ The blood supply to the auricle is through the posterior auricular artery and

superficial temporal artery.
■ The posterior auricular artery runs in the sulcus between the auricular cartilage
and the mastoid process of the temporal bone.
■ This vessel supplies the posterior ear skin and posterior auricular muscle and
sends perforating branches that pierce the auricular cartilage in the region of
the triangular fossa, cymba conchae, cavum conchae, helical root, and ear
lobe to supply the anterior ear skin (FIG 1B).2,3
■ The posterior auricular artery anastomoses with the superficial temporal
artery through the superior auricular artery.
■ Venous drainage is via the posterior auricular vein into the external jugular
system and the superficial temporal and retromandibular veins.
■ This rich anastomotic network of blood vessels is the basis for the
postauricular flap.
FIG 1 • A. Anatomy of the external ear. B. Arterial
anatomy of the posterior ear. (The right ear is shown.)
The posterior auricular artery provides the blood supply
for the postauricular flap. It anastomoses with the
superficial temporal artery via the superior auricular
artery.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A thorough history and physical should be obtained prior to any operation by

paying close attention to significant comorbidities, including smoking history,
prior surgeries including scars in the postauricular area, and medications that
may predispose the patient to bleeding.
■ Patients who wear glasses should also be educated in postoperative care and
management of incisions.
■ They may need to remove the earpiece of the glasses on the reconstructed
side until adequate healing has occurred, and then replace the earpiece.
■ Defects resulting from oncologic resection should consider documentation for
clear margins or Mohs excision prior to definitive reconstruction.
IMAGING
■ Patients who have undergone resection for aggressive cutaneous malignancies
may require imaging studies or staging and to rule out metastatic disease.
SURGICAL MANAGEMENT
■ Postauricular flaps used in ear reconstruction can be based in the superior,
middle, or inferior postauricular and mastoid region.2
■ They are indicated for marginal reconstruction, in combination with cartilage
grafts to support and give definition to the helix, in a staged manner as
originally proposed by Dieffenbach (FIG 2).
Preoperative Planning
■ The extent of the defect should be evaluated prior to reconstruction.
■ Postauricular flaps are preferred over wedge resections and closure, eg, for
defects that encompass more than one-fourth to one-third of the outer
circumference of the ear.
■ The defect size should be compared to the amount and reach of available
postauricular skin.
■ Pathology should be reviewed to confirm that clear margins have been
obtained prior to proceeding with reconstruction.
■ In the setting of melanoma and squamous cell carcinoma, it is important also
that the sentinel lymph nodes are negative as well.
■ If the patient is taking anticoagulants, these should ideally be discontinued
before surgery to minimize risks of hematoma.
■ If the anticoagulation cannot be continued, the patient should be made to
understand the increased risks of bleeding and hematoma as complications.

Positioning
■ Proper patient positioning is critical to prepare for the reconstruction again to
allow the reconstructive surgeon the best access, exposure, and approach to the
ear.
■ The patient is placed into the supine position, and the bed can be turned 180
degrees to give access to both ears.
■ It is helpful to prep and drape the entire head again to give full access and
exposure to both ears.
■ Local anesthetic with epinephrine is useful, despite anecdotal reports of
potential risks for inducing ischemia to the ear.

FIG 2 • Method of reconstructing marginal ear defects
with the postauricular flap, as originally described by
Dieffenbach. The postauricular flap is initially elevated
(A), and the flap is transposed from the posterior auricle
to the anterior auricle during inset (B). A helical
cartilage graft is strongly recommended to preserve the
shape of the ear and give definition to the helix,
although not included in the original description by
Dieffenbach. At a second stage, the base of the flap is
divided (C), and the flap donor site is skin grafted (D).
T E C H N I Q U E S
■ Postauricular Flap for Marginal Auricular Defects
Stage 1
■ The postauricular flap is used for reconstruction of marginal auricular
defects that include the helix as part of a two-stage reconstruction (TECH
FIG 1A).
■ In the first stage, a posteriorly based flap is elevated and advanced anteriorly
in a horizontal configuration (TECH FIG 1B).
■ The flap should include the subcutaneous fat but not the periosteum.
■ Although an extended retroauricular advancement flap that includes hair-
bearing scalp skin has been described by Butler,4 in most cases, the base of
the flap is in the mastoid region and the postauricular artery is not divided,
if possible.
■ Although the original description of the technique by Dieffenbach specified
a skin flap only, a cartilage graft provides better definition of the helix and
prevents collapse of the auricle as the flap heals and contracts.
■ The naturally curved cartilage from the contralateral conchal bowl serves
as an excellent source of graft material.
■ Either a postauricular approach (TECH FIG 1C) or anterior incision made
just inside the antihelical fold can be used to harvest the cartilage.

■ The distal postauricular flap is used to resurface the anterior skin of the
auricle (TECH FIG 1D,E).
■ Mattress sutures are used at the margin of the helix, to help prevent
notching by providing skin eversion.
■ The auricle will be pinned back by the attachment of the flap to the
mastoid region.
Stage 2
■ Four to 6 weeks later, after secondary revascularization, the posterior aspect
of the flap is divided.
■ The ear can then be elevated, and the flap is advanced and inset into
posterior surface of the auricle to complete the reconstruction.
■ The mastoid donor site, which has periosteum at its base, is reconstructed
with a full-thickness skin graft that is bolstered with a tie-over dressing for 5
days (TECH FIG 2A).
■ The completed reconstruction is shown in TECH FIG 2B.
■ A second example of a lower third auricular defect involving part of the
lobule that was reconstructed with a more inferiorly based postauricular flap
is shown in TECH FIG 3.

TECH FIG 1 • A. A helical rim defect of the central
one-third of the ear. The lower incision, which has
been sutured, is from a sentinel lymph node biopsy. B.
A postauricular flap is designed, extending into the
postauricular sulcus, but the postauricular artery is not
divided. C. A contralateral conchal cartilage graft is
harvested to provide support and definition to the
helical rim. The graft may be obtained through an
anterior or posterior (shown here) approach. D. The
conchal cartilage graft has been secured in place with
either permanent or long-acting absorbable sutures.
The postauricular flap has been elevated. The plane
of dissection is above the perichondrium of the ear
cartilage and the periosteum of the mastoid process

bone. E. Completed flap inset. The edges of the flap
at the margin of the ear are everted to help prevent
notching at the helix.
TECH FIG 2 • A. At the second stage, 4 to 6 weeks
later, the base of the flap is divided and the proximal
flap is advanced onto the posterior auricle and sulcus.
A full-thickness skin graft is then placed over the
mastoid periosteum and secured with a bolster
dressing. B. Postoperative results following
postauricular flap and conchal cartilage graft
reconstruction of a middle one-third auricular helical
defect.

TECH FIG 3 • A. Lower one-third of the auricle
marginal surgical defect. The auricular cartilage has
been spared. B. Completed postauricular flap
elevation, including the postauricular skin and
subcutaneous fat with the flap, while preserving the
perichondrium and periosteum of the donor site. C.
Completed postauricular flap inset. D. Postoperative
result following postauricular flap reconstruction and
second-stage flap division and skin grafting of the
donor site for a lower one-third auricular defect.
PEARLS AND PITFALLS
Preoperative
care
■ The use of local anesthetic with epinephrine is not contraindicated
in auricular reconstruction.
Technique
■ The defect should be assessed accurately to determine whether a
postauricular flap reconstruction is feasible without creating a
greater deformity and distortion of the ear.
■ Cartilage grafts are necessary to preserve the shape of the ear. An
early result without cartilage may seem satisfactory, but without
structural support, the flap will contract with time and the shape of
the ear will be distorted.
Hemostasis
■ Hemostasis is critical as a hematoma can severely compromise the
viability of the cartilage, distort the underlying structure, and
adversely impact the final cosmetic result.
Postoperative
care
■ Avoid any pressure or trauma to the reconstructed ear, including
wearing of glasses and sleeping on the side of the reconstructed
ear.
POSTOPERATIVE CARE
■ Because permanent sutures are used to reapproximate the skin, the sutures will
need to be removed in approximately 7 to 10 days.

■ The incision should be cleaned regular with soap and water, paying careful
attention to avoid trauma or pressure to the ear.
■ Pressure dressing is usually not recommended.
■ Antibiotic ointment can be used following surgery at the surgeon’s
discretion.
■ Patients should avoid sleeping on the side of the ear that has been
reconstructed.
■ Patients should also refrain from wearing glasses.
■ If patients do not wear contacts and have to wear glasses, it is recommended
that the earpiece on the reconstructed side be removed to avoid any potential
trauma to the reconstructed ear.
COMPLICATIONS
■ Infection of the ear and cartilage can be a serious complication that can lead to
loss of additional cartilage and necrosis of the tissue. This can then result in a
much more extensive ear defect, larger than the original defect.
■ Although extended prophylactic antibiotics are not generally recommended, a
fluoroquinolone is considered the antibiotic of choice in the perioperative
period due to good tissue penetration of cartilage and coverage for
Pseudomonas aeruginosa.
■ Bleeding can lead to significant distortion of the ear and underlying cartilage.
Meticulous hemostasis is mandatory at the time of the operation.
■ Notching of the helix is a common complication following reconstruction of
marginal defects.
■ This can usually be revised satisfactorily several months later after primary
healing of the cartilages and resolution of tissue edema.
REFERENCES
1. Masson JK. A simple island flap for reconstruction of concha-helix defects. Br
J Plast Surg. 1972;25:399-403.
2. Cordova A, D’Arpa S, Pirello R, et al. Retroauricular skin: a flaps bank for ear
reconstruction. J Plast Reconstr Aesthet Surg. 2008;61:544-551.
3. Yotsuyanagi T, Watanabe Y, Yamashita K, et al. Retroauricular flap: its
clinical application and safety. Br J Plast Surg. 2001;54:12-19.
4. Butler CE. Extended retroauricular advancement flap reconstruction of a full-
thickness auricular defect including posteromedial and retroauricular skin. Ann
Plast Surg. 2002;49(3):317-321.

31
CHAPTER
Reconstruction of the Ear
Lobe
Matthew M. Hanasono
DEFINITION
■ Ear lobe defects can result following trauma or following resection of
cutaneous malignancies.
■ The simplest types of resection and reconstruction for skin cancers on the ear
lobe are amputation-type resections. These can be carried out along a curved
line to approximate the curvature of the lower border of the ear lobe. Most of
the procedures will result in loss of volume or height (ptosis) of the lobule.
■ The ear lobe is difficult to reproduce surgically because it has a characteristic
protuberance that consists of fibrofatty tissue rather than cartilage.
■ Many techniques have been described for ear lobe reconstruction.1–8
■ Most require more than a one-stage operation.
ANATOMY
■ Ear lobes (ear lobules) occur in the lower third of the ear. They consist of
areolar and fibrofatty tissue and lack cartilage.
■ The ear lobes are usually about 2 cm long and may or may not be attached to
the cheek to a variable degree, a characteristic that is thought to be inherited.
■ The ear lobe should lie roughly even at the level of the nasal ala, which is
typically half the distance between the eyes and mentum.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A thorough history and physical should be obtained prior to any operation
paying close attention to significant comorbidities, including smoking history,
and prior surgeries including scars in the area that may impact the design
preauricular and postauricular flaps.

■ Preauricular and postauricular skin laxity should be assessed to plan whether a
single folded flap can be used or if double-opposing flaps will be required.
■ For example, young patients and patients who have had a face-lift may not
have adequate preauricular skin laxity to create a flap and still close the donor
site primarily. Sentinel lymph node biopsy and neck dissection incisions may
also preclude some local flaps.
IMAGING
■ Patients who have undergone resection for cutaneous malignancies such as
melanoma and squamous cell carcinoma may require imaging studies for
staging and to rule out potential for metastatic disease.
SURGICAL MANAGEMENT
■ Numerous reconstructive techniques have been described to restore the ear
lobe, all based on single or double local flaps.
■ Based on the availability of preauricular and postauricular tissue, a single
folded flap or double-opposing flaps can be used for ear lobe reconstruction.
■ Single flaps are usually folded and may be designed as bilobed flaps.
■ Use of an anteriorly based transverse folded flap is known as Gavello
procedure.3
■ The advantage of this procedure is that it is usually a single-staged procedure.
A cartilage graft may be added to give support and prevent contracture, and
the donor site is usually skin grafted.
■ The negative is the long length of the flap and the possibility of a donor-site
scar (FIG 1A).
■ Folded preauricular or postauricular flaps usually need a thin cartilage graft to
maintain ear lobe height (FIG 1B).
■ Double-flap reconstruction with preauricular and postauricular skin flaps
usually does not require grafts (FIG 1C,D).6
■ The author’s preferred technique is to use double-opposing preauricular and
postauricular flaps for ear lobe reconstruction.
Preoperative Planning
■ Pathology should be reviewed to confirm that clear margins have been
obtained prior to proceeding with reconstruction. In the setting of melanoma, it
is important also that the sentinel lymph nodes are negative as well.
■ The extent of the defect should be evaluated prior to reconstruction. Partial

defects are more likely to be able to be managed with a single flap and less
likely to need a cartilage graft to maintain ear lobe height.
■ If earrings are to be worn postoperatively, a hole in the cartilage graft, if used,
will likely need to be made by the surgeon.
■ If the reconstructed ear lobe cannot be made to match the contralateral ear lobe
in height, the contralateral ear lobe can be reduced by performing an
amputation or posterior skin transverse wedge excision.
■ For single-lobe reconstructions in which a cartilage graft is used, nasal septal
cartilage or conchal cartilage can be used.
FIG 1 • Some methods of ear lobe reconstruction with
local flaps. A. Transversely oriented, bilobe flap

originally described by Gavello. B. Inferiorly based
preauricular flap that is folded longitudinally. A cartilage
graft is needed to maintain ear lobe height. C. Double-
opposing flap technique in which a postauricular flap
becomes the posterior surface of the ear lobe and a
preauricular flap becomes the anterior surface of the
ear lobe. No cartilage graft is usually needed. The
postauricular flap is divided at its base to release the
ear lobe from the postauricular (mastoid) region, and
the donor site is skin grafted at a second stage. D.
Double-opposing flap technique in which a superiorly
based postauricular (infra-auricular) flap becomes the
posterior surface of the ear lobe and a preauricular flap
becomes the anterior surface. The donor sites are
closed primarily, and a second stage may not be
necessary, although, in practice, a second stage is
often needed to revise the anterior attachment of the
reconstructed ear lobe.
Positioning
■ The patient is placed into the supine position, and both ears should be prepped
and draped to give full access and exposure to both ears.
■ Additionally, if septal cartilage is to be used as a graft, the nose should be
exposed and prepped.
■ Local anesthetic with epinephrine is useful, despite anecdotal reports of
potential risks for inducing ischemia to the ear. This can also be injected into
the subperichondrial plane to assist with septal cartilage harvest, in addition to
applying 4% cocaine-soaked pledgets against the septal mucosa.
T E C H N I Q U E S
■ Double-Opposing Preauricular and Postauricular

Flaps
Stage 1
■ Although superiorly based postauricular skin flaps, extending into the infra-
auricular neck, have been described,7 a more reliable postauricular skin flap
is an inferiorly based one used to reconstruct the posterior surface of the ear
lobe (TECH FIG 1A).
■ The flap is elevated from the mastoid process of the temporal bone, sparing
the periosteum.
■ An inferiorly based preauricular skin flap is designed (TECH FIG 1B).
■ The width of the flap should be at least the height of the ear lobe to be
reconstructed, if possible.
■ Slight overcorrection is desirable in that the flap will contract slightly and,
also, this allows the scar to be hidden posteriorly.
TECH FIG 1 • A. Right ear lobe defect to be
reconstructed with double-opposing postauricular and
preauricular flaps. The postauricular flap is elevated,
leaving the mastoid periosteum intact. B. A
preauricular flap is then elevated, leaving the parotid
fascia intact. The width of this flap is ideally at least as
large as the height of the original ear lobe.

■ The flap should include the subcutaneous fat and be elevated above the
parotid fascia.
■ The flaps are opposed to each other.
■ A cartilage graft is not necessary to prevent contracture in double-opposing
flap reconstruction and will also make the ear lobe unnaturally stiff and
bulky.
■ Because the postauricular flap is still connected to the mastoid skin, the ear
lobe will be pinned back temporarily until second-stage surgery.
Stage 2
■ At a second stage, the postauricular skin flap is divided, releasing the
reconstructed ear lobe from the mastoid region (TECH FIG 2A).
■ The postauricular donor site is skin grafted.
■ The base of the anterior flap can also be refined by partial division, if
needed.
■ The postoperative result is shown in TECH FIG 2B.
TECH FIG 2 • A. The preauricular and postauricular
flaps have been joined, and at a second stage, the
base of the postauricular flap has been divided,
releasing the proximal flap and allowing it to be inset.
The donor site is reconstructed with a full-thickness
skin graft. B. Postoperative appearance showing good

ear lobe height and cosmesis.
PEARLS AND PITFALLS
Preoperative
Care
■ The use of local anesthetic with epinephrine is not contraindicated in
auricular reconstruction and minimizes the need for cauterization.
Technique
■ The choice of flap is made based on the laxity of the preauricular an
postauricular skin.
■ Single longitudinally folded flaps often contract and do not give
adequate height (ptosis) unless they are very wide and a cartilage gra
added to maintain the ear lobe shape.
■ Double-opposing flaps have less tendency to contract, even without
cartilage grafts.
■ Consider shortening the contralateral ear lobe if the reconstructed ea
lobe does not match/cannot be made to match.
■ Loss of ear lobe height can be avoided by not longitudinally folding
single flap or by using an anterior and a posterior flap (FIG 2).
■ Alternately, loss of length can be avoided by placing a nonanatomic
cartilage graft into a single folded flap.
FIG 2 • A. A longitudinally folded preauricular flap is used for ear
lobe reconstruction. B. Although the reconstructed ear lobe initially
looks like it has good height, it will contract because no cartilage

graft was used. C. Postoperative appearance, showing loss of ear
lobe height.
Postoperative
Care
■ Avoid any pressure or trauma to the reconstructed ear including wea
of glasses and sleeping on the side of the reconstructed ear.
POSTOPERATIVE CARE
■ Since permanent sutures are used to reapproximate the skin, the sutures will
need to be removed in approximately 7 to 10 days.
■ The incision should be cleaned regularly with soap and water, paying careful
attention to avoid trauma or pressure to the ear.
■ Pressure dressings are not recommended, because they may compromise
blood flow to the flap.
■ Patients should avoid sleeping on the side of the ear that has been
reconstructed.
COMPLICATIONS
■ If there is significant tension on the closure, there is a risk for dehiscence.
■ Again, the patient should avoid any trauma or displacement of the ear during
the early recovery period to avoid any undue tension on the closure.
■ Partial or total flap loss is a risk that can be minimized by keeping skin flaps
thick, to maximize vascularity, and avoiding inset under tension.
■ In some cases, tight sutures must be released, even if it means needing to do a
revision or delayed wound closure.
■ Medicinal leeches may also be useful for treating flap venous congestion.
REFERENCES
1. Brent B. Earlobe reconstruction with an auriculomastoid flap. Plast Reconstr
Surg. 1976;57:389.
2. Clevens RA, Baker SR. Plastic and reconstructive surgery of the earlobe.
Facial Plast Surg. 1995;11:301-309.
3. Emiroglu M, Al-Saedi M. Gavello’s procedure: an old earlobe reconstruction
method, revisited and touched up. Aesthetic Plast Surg. 2001;25:187-188.
4. Okada E, Maruyama Y. A simple method for ear lobe reconstruction. Plast
Reconstr Surg. 1998;101:162-166.
5. Sclafani AP, Mashkevich G. Aesthetic reconstruction of the auricle. Facial

Plast Surg Clin North Am. 2006;14(2):103-116.
6. Sleilati F. Immediate ear lobe reconstruction with double-crossed skin flaps. J
Plast Reconstr Aesthet Surg. 2006;59:1003-1005.
7. Van Geertruyden JP. Earlobe reconstruction with a reverse-flow
chondrocutaneous flap. Br J Plast Surg. 2002;55(3):253-255.
8. Yotsuyanagi T, Yamashita K, Sawada Y. Reconstruction of congenital and
acquired earlobe deformity. Clin Plast Surg. 2002;29(2):249-255.

CHAPTER
Wedge Reconstruction of
Partial Auriculectomy
Defects
Edward I. Chang and Matthew M. Hanasono
DEFINITION
■ Partial ear defects can result following trauma or more commonly following
resection of cutaneous malignancies.
■ Wedge resection and closure techniques are appropriate for defects up to one-
third of the outer circumference of the ear occurring in the upper two-thirds of
the ear.
■ Reconstruction of such defects aims to restore the natural anatomic structures
and landmarks of the ear and ideally should maintain balance and symmetry
with the contralateral ear.1–3
ANATOMY
■ The ear is an important component both in the aesthetic balance of the face
and in auditory function (it funnels sound into the external auditory canal and
selectively amplifies sounds in the frequency range of human speech).
■ The anatomic landmarks of the ear are defined by the underlying cartilaginous
framework, which create the contours that should be restored as best as
possible during wedge reconstruction of the ear.
■ The outer rim or helix creates the outer curvature of the ear and originates
from the face at the root of the helix (FIG 1).
■ Concentrically within the helix is the antihelix, which separates into two
separate crura in the upper third of the ear that define the triangular fossa.

FIG 1 • Anatomy of the auricle. Landmarks need to be
precisely realigned in ear wedge resection and
reconstruction.
■ The scapha is the concave rim that separates the helix and antihelix.
■ The concha lies within the antihelix and is the structure that leads to the
external auditory meatus.
■ The anterior border of the external auditory meatus is defined by the tragus.
In the lower third of the ear lies the lobule or ear lobe, which does not
contain cartilage.3–5
■ The ideal proportions of the external ear are variable based on age and gender.
■ The length of the ear should be approximately twice the width and should
project 1.5 to 2 cm from the head.4
■ The superior most part of the ear should be level with the position of the
brow or just cephalad to the orbits, which are typically situated in the middle
of the face.
■ The ear lobe should lie roughly even at the level of the nasal ala, which is

typically half the distance between the eyes and mentum.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A thorough history and physical should be obtained prior to any operation
paying close attention to significant comorbidities including smoking history,
prior surgeries including scars in the area that may impact the design of the
wedge resection, and medications that may predispose the patient to bleeding.
■ Patients who wear glasses should also be educated in postoperative care and
management of incisions.
■ They may need to remove the earpiece of the glasses on the reconstructed
side until adequate healing has occurred before replacing the earpiece.
■ Defects resulting from oncologic resection should consider documentation for
clear margins or Mohs excision prior to definitive reconstruction.
IMAGING
■ Patients who have undergone resection for cutaneous malignancies such as
melanoma and squamous cell carcinoma may require imaging studies for
staging and to rule out potential for metastatic disease.
SURGICAL MANAGEMENT
■ Reconstruction of the ear using a wedge resection approach will result in an
asymmetry compared to the contralateral ear.6,7
■ The reconstructed ear will typically be smaller and may also have increased
projection compared to the normal ear.
■ The anticipated result should be discussed with the patient prior to
embarking on reconstruction using this technique.
■ In the trauma setting, nonviable tissue should be debrided prior to definitive
reconstruction.
■ Topical sulfamylon can be helpful in preventing subsequent chondritis, given
the effective bioavailability with cartilage penetration.
■ After adequate healing and, in the case of cancer, a satisfactory surveillance
period during which no recurrences are detected, wedge resection of the
contralateral ear for symmetry can be offered to the patient.
Preoperative Planning
■ The extent of the defect should be evaluated prior to reconstruction.
■ A wedge resection technique is appropriate for defects that encompass less

than one-third of the outer circumference of the ear.
■ Larger defects will create significant projection and cupping of the ear.
■ Pathology should be reviewed to confirm that clear margins have been
obtained prior to proceeding with reconstruction. In the setting of melanoma
and squamous cell carcinoma, it is important also that the sentinel lymph nodes
are negative as well.
■ Local anesthetic with epinephrine is useful, despite anecdotal reports of
potential risks for inducing ischemia to the ear.
Positioning
■ Proper patient positioning is critical in preparation for the reconstruction again
to allow the reconstructive surgeon the best access, exposure, and approach to
the ear.
■ The patient is placed into the supine position, and the bed can be turned 180
degrees to give access to both ears.
■ It is helpful to prep and drape the entire head again to give full access and
exposure to both ears.
T E C H N I Q U E S
■ Wedge Resection of Helix
■ The length of the curvature of the missing helix is measured, and the edges
of the defect are approximated using forceps to assess whether a wedge
resection approach will create an unacceptable deformity, asymmetry, or poor
aesthetic result.
■ The edges of the helix and antihelix should be marked to ensure precise
alignment of these structures.
■ Local anesthetic is then injected and several minutes are allowed to achieve
the desired hemostatic effect.
■ The wedge excision is marked that extends into the scapha and antihelix and
potentially into the concha depending on the size of the defect.
■ A full-thickness wedge is resected from the remaining ear.8,9
■ The cut edges of the ear cartilages are repaired first, using monofilament
suture on tapered needles.

■ Clinical examples of upper third and middle third wedge excision and
reconstructions are shown in TECH FIG 1.
TECH FIG 1 • Wedge resection and reconstruction to
repair partial auriculectomy defect in the superior (A–
D) and middle (E–H) one-third of the ear following
removal of skin cancer.
■ Variations
■ A wedge-type excision and closure will typically result in a small
redundancy of cartilage near the apex of the wedge, causing cupping of the
reconstructed auricle.
■ This can be managed by a keyhole-type excision of cartilage (TECH FIG
2).
■ TECH FIG 3 shows other wedge-type excisions.

TECH FIG 2 • Full-thickness wedge resection and
reconstruction using “keyhole-type” cartilage excision
to prevent redundancy of the cartilage at the apex of
the wedge. Planned excision (A), removal of “keyhole”
(B), and final result (C).
■ The skin is then closed using permanent suture, everting the skin edges as
much as possible.

■ Mattress sutures are often helpful to maximize the eversion of the skin
edges. The landmarks should be realigned based on the markings.
■ The posterior skin is closed in an identical fashion using permanent sutures,
again everting the skin edges as much as possible.
TECH FIG 3 • Variations of cartilaginous wedge
resections to avoid redundancy of the cartilage at the

apex of the wedge and a cup deformity of the
reconstructed auricle.
PEARLS AND PITFALLS
Preoperative
care
■ The use of local anesthetic with epinephrine is not contraindicated
in auricular reconstruction.
Technique
■ The defect should be assessed accurately to determine whether a
wedge resection is even feasible without creating a greater
deformity and distortion of the ear.
■ The structures of the ear should be realigned precisely with perfect
skin eversion to avoid notching and a suboptimal aesthetic result.
■ A small keyhole or other type of subcutaneous cartilage excisions
at the apex of the wedge can help avoid cupping of the ear.
Hemostasis
■ Hemostasis is critical as a hematoma can severely compromise the
viability of the cartilage, distort the underlying structure, and
adversely impact the final cosmetic result.
Postoperative
care
■ Avoid any pressure or trauma to the reconstructed ear including
wearing of glasses and sleeping on the side of the reconstructed
ear.
POSTOPERATIVE CARE
■ Because permanent sutures are used to reapproximate the skin, the sutures will
need to be removed in approximately 7 to 10 days.
■ The incision should be cleaned regular with soap and water, paying careful
attention to avoid trauma or pressure to the ear.
■ Pressure dressings are usually not recommended.
■ Antibiotic ointment can be used following surgery at the surgeon’s
discretion.
■ Patients should avoid sleeping on the side of the ear that has been
reconstructed. Patients should also refrain from wearing glasses.
■ If patients do not wear contacts and have to wear glasses, it is recommended
that the earpiece on the reconstructed side be removed to avoid any potential
trauma to the reconstructed ear.

COMPLICATIONS
■ If there is significant tension on the closure, there is a risk for dehiscence.
Again, the patient should avoid any trauma or displacement of the ear during
the early recovery period to avoid any undue tension on the closure.
■ Infection of the ear and cartilage can be a serious complication that can lead to
loss of additional cartilage and necrosis of the tissue.
■ This can then result in a much more extensive ear defect, larger than the
original defect.
■ Although extended prophylactic antibiotics are not generally recommended,
a fluoroquinolone is considered the antibiotic of choice in the perioperative
period due to good tissue penetration of cartilage and coverage for
Pseudomonas aeruginosa.
■ Bleeding can lead to significant distortion of the ear and underlying cartilage.
Careful hemostasis is mandatory at the time of the operation.
■ Notching of the helix is a common complication following reconstruction of
the ear primarily using a wedge resection.
■ This can result from excess tension on the closure or potentially from poor
technique in skin eversion but can usually be revised satisfactorily several
months later after primary healing of the cartilages and resolution of tissue
edema.
REFERENCES
1. Sclafani AP, Mashkevich G. Aesthetic reconstruction of the auricle. Facial
Plast Surg Clin North Am. 2006;14(2):103-116.
2. Taylor JM, Rajan R, Dickson JK, Mahajan AL. Maintaining ear aesthetics in
helical rim reconstruction. Ann Plast Surg. 2014;72(3):318-322.
3. Tolleth H. Artistic anatomy, dimensions, and proportions of the external ear.
Clin Plast Surg. 1978;5(3):337-345.
4. Ferrario VF, Sforza C, Ciusa V, et al. Morphometry of the normal human ear:
a cross-sectional study from adolescence to mid-adulthood. J Craniofac Genet
Dev Biol. 1999;19(4):226-233.
5. Mohamed K, Christian J, Jeyapalan K, et al. Identifying position, visibility,
dimensions, and angulation of the ear. J Rehabil Res Dev. 2014;51(4):599-608.
6. Brodland DG. Advanced reconstruction of the ear: a framework for successful
wound closure. Dermatol Surg. 2014;40(suppl 9):S71-S85.
7. Fata JJ. Composite chondrocutaneous advancement flap: a technique for the
reconstruction of marginal defects of the ear. Plast Reconstr Surg.

1997;99(4):1172-1175.
8. Ghassemi A, Modabber A, Talebzadeh M, et al. Surgical management of
auricular defect depending on the size, location, and tissue involved. J Oral
Maxillofac Surg. 2013;71(8):e232-e242.
9. Krunic AL, Weitzul S, Taylor RS. Chondrocutaneous advancement flap for
reconstruction of helical rim defects in dermatologic surgery. Australas J
Dermatol. 2006;47(4):296-299.

33
CHAPTER
Section X: Nose
Nasal Reconstruction With
Banner Flaps, Bilobed
Flaps, and Nasolabial Flaps
Michael V. Chiodo and Pierre Saadeh
DEFINITION
■ Banner and bilobed flaps are local rotation and transposition flaps that provide
well-matched color and textured skin for small (0.7–1.2 and 0.5–1.5 cm,
respectively) nasal cutaneous defects.
■ When compared with banner or single transposition flaps, bilobed or “double
transposition” flaps can move tissue over a longer distance from the mobile
soft tissue of the upper nose to the nasal tip.
■ Although full-thickness skin grafts may aid in reconstructing small defects of
the upper two-thirds of the nose, they are often too thin to mimic the native
contours of the nasal tip.
■ The nasolabial crease is one of the most important boundaries in facial
aesthetics. It is the delineation between the cheek and the lips and the cheek
and the nose.
■ Because of its proximity to the nose and lips, flaps from this region have a
critical role in nasal and cutaneous lip reconstruction.
■ Nasolabial flaps are cheek flaps harvested from the strip of prominent cheek
fat just lateral to the nasolabial crease referred to as the nasolabial fold.
■ These flaps are most useful for small to medium-sized full-thickness skin
defects of the nasal alae, caudal nasal sidewall, and upper cutaneous lip.
■ They take advantage of the redundant nature of the skin of the nasolabial
fold and its reliable underlying blood supply to achieve transfer of sizeable

flaps and ability for primary closure of donor defects with favorable scar
placement along aesthetic unit borders.
■ Nasolabial flaps are largely classified as transposition, advancement, or
interpolated flaps. By definition, the base of an interpolated flap is not
continuous with the defect of question, so the pedicle must cross over or under
intervening tissue. Therefore, interpolated nasolabial flaps ultimately require
division and inset of the flap’s pedicle in a second-stage procedure, whereas
transposition and advancement flaps can be done as single-stage operations.
ANATOMY
■ The nose can be divided into nine aesthetic subunits with three paired units
(alar base, alar wall, dorsal sidewall) and three central subunits (tip, columella,
and dorsum) (FIG 1A).
■ These units are separated by nasal contour lines between areas of different
skin texture and thickness.
■ Additionally, the nose can be broken into thirds based on skeletal support:
proximal third is supported by the nasal bones, middle third by the upper
lateral cartilages, and distal third by lower lateral cartilages (FIG 1B).
■ The nose should be thought of as a trilaminate structure with external skin and
muscle (nasalis) supported by a skeleton of cartilage and bone and an internal
lining.
■ Banner and bilobed flaps are random pattern cutaneous flaps dependent on the
subdermal plexus for blood supply.
■ The nasalis muscle, which is often included in these flaps, consists of
transverse and alar parts that overlie the nasal sidewalls with an aponeurosis
extending across the nasal dorsum.
■ The anatomic basis for the nasolabial crease is controversial. There are two
prevailing theories: a muscular theory and a fascial theory.
■ Supporters of the muscular theory discuss a “fold muscle,” which originates
from the upper lip elevators and progresses through the nasolabial fold and
crease on its way to the upper lip vermillion.
■ Proponents of the fascial theory suggest the nasolabial crease is not created
by muscular insertion, but rather developed by the fascial insertion of the end
portion of the superficial musculoaponeurotic system (SMAS) into the skin at
the junction between the upper and lower cutaneous lips and the cheek.
■ There is an abundance of subcutaneous fat directly lateral to the nasolabial
crease, referred to as the nasolabial fold. The skin of the cheek in this area is