Versatility of Posterior Auricular Flap in PartialEar Reconstruction
Fabrizio Schonauer, M.D.,Ph.D.
Gunasaker Vuppalapati,M.D.
Sergio Marlino, M.D.Adriano Santorelli, M.D.
Luigi Canta, M.D.Guido Molea, M.D., Ph.D.
Naples, Italy
Background: The posterior auricular flap alone has always been popular be-cause of its prompt availability, its rich vascularity, and the ease of closing thedonor-site defect primarily.Methods: Fifty-seven patients with partial ear defects covered with posteriorauricular flaps during the period between 2002 and 2007 were reviewed. In theauthors’ series, posterior auricular flaps were harvested based on a simplerandom vascularization and tailored to reach almost any defect of the ear by asimplified and standardized approach.Results: The authors propose a simple nomenclature after grouping the flapsaccording to skin paddle type, pedicle type, pedicle base, flap transfer method,and flap movement; they present a standardized algorithm with which to choosethe flap design for a given defect from this group.Conclusions: The authors contribute three new flap designs to enhance theversatility of the posterior auricular flap. These are the superiorly and inferiorlybased twisted island flaps and the posterior auricular propeller flap. (Plast.Reconstr. Surg. 126: 1, 2010.)
Reconstruction of most partial ear defectscan be achieved with the posterior auric-ular flap alone.1 However, different loca-
tions of the defect require different designs ofthe posterior auricular flap. Various designshave been reported for selected sites in the ear,each one with individual limitations.2–9 The aimof this article is to group these different flaps tosolve the dilemma of the right indication. Wealso present a simple and standardized algo-rithm with which to choose the flap design fora given auricular defect.
APPLIED ANATOMYThe medial or posterior surface of the ear is
hidden except in prominent ears. Thus, thissurface along with the retroauricular area hasalways been a popular donor site both forfull-thickness skin grafts and for posterior au-ricular flaps.10,11
The blood supply to the skin of the posteriorauricular area is unusually rich. This is derivedfrom an arterial arcade situated in the auricu-locephalic groove between the auricular carti-lage and the skull deep to the auricularis pos-
terior muscle. This arterial arcade is formed bythe auricular branch of the posterior auricularartery and posterior branch of the superficialtemporal artery. Three arteries arising from thisarcade supply the medial or posterior surface ofthe ear. These were described as upper, middle,and lower divisions of the posterior auricularartery by Park et al.10
The retroauricular skin over the mastoid isalso supplied by a number of unnamed branchesof this auriculocephalic arterial arcade. Thesebranches fan out in either direction from thisdeep arcade, surfacing farther away from theauriculocephalic groove. As a result, the skinoverlying the auriculocephalic groove is pecu-liarly characterized by dense superficial anddeep dermal plexuses receiving blood from alldirections. Thus, the vascular anatomy of theauriculocephalic groove resembles that of thenasolabial fold. This explains the basis of raisingunusually long and thin random flaps in both ofthese locations. Venous drainage follows thesuperficial and deep dermal plexus. The poste-rior auricular area drains into the posterior au-
ricular vein and then into the external jugu-lar vein.
NOMENCLATURETerminology in this area is always a source of
controversy. The controversy mainly is related tothe commonly used terms: postauricular, retro-auricular, and posterior auricular. This is mainlybecause the territories of above terms are illdefined. Tanzer categorically criticized usingthe term “postauricular” instead of “retroauricu-
lar” in his discussion article in 1981.12 In ourarticle, we use the term “posterior auricular,”indicating the auriculomastoid area that in-cludes the posterior (medial) surface of the ear,the auriculocephalic groove, and the mastoid(retroauricular) area.
Over the past 50 years, numerous designs ofthe posterior auricular flap have been reportedwith various terminologies. In this article, we pro-pose a simplified nomenclature (Table 1) aftergrouping flaps according to skin paddle type,pedicle type, pedicle base, flap transfer method,and flap movement.
PATIENTS AND METHODSFifty-seven patients with partial ear defects
covered with posterior auricular flaps during theperiod between 2002 and 2007 were reviewed.This series included 40 defects over the anterior
Table 1. Classification of Posterior Auricular Flaps
Skin Paddle Type Pedicle Type Pedicle Base Method of Transfer Movement
Island Deepithelialized skin pedicle Superior Folded pedicle Through the cartilageTwisted pedicle
Inferior Folded pedicleTwisted pedicle
Subcutaneous pedicle Central Revolving doorEccentric Propeller Around the cartilage
Peninsular Skin pedicle Superior TranspositionInferior
Fig. 1. Superiorly based folded deepithelialized skin pedicle posterior auricular flap. (Left) Right ear: defect of the inferior crus afterexcision of basal cell carcinoma. (Center) Flap transfer by upward pedicle folding. (Right) Flap tailoring and insetting.
Fig. 2. Superiorly based twisted deepithelialized skin pedicle posterior auricular flap.(Above, left) Right ear: skin lesion at the antihelix and planned margin of excision.(Above, right) Flap design with superior pedicle and area to be deepithelialized. (Below,left) Skin paddle and deepithelialized skin pedicle. (Below, right) Flap transfer by pedi-cle twist and skin island insetting.
surface, nine helical rim defects, four ear lobuledefects, and four posterior defects (Table 2).These defects were secondary to elective exci-sion of skin lesions. The lesions were excisedaccording to oncologic principles. All the flapsused in this series were harvested along the au-riculocephalic groove. Flap planning startedwith marking the skin paddle by transferring themeasured template of the defect to the posteriorauricular area, centering the flap and the flappedicle on the auriculocephalic groove. The re-maining markings and steps of the procedurewere quite different for individual flaps. Proce-dures were performed under local anesthesia byinfiltration of mepivacaine chlorohydrate withadrenaline 1:100,000.
Marking involved an ellipse drawn with themain axis along the auriculocephalic groove.The ellipse included the skin paddle and thepedicle area. The pedicle of the flap could besuperiorly or inferiorly based according to theposition of the defect. The pedicle area wasdeepithelialized and the skin edges on bothsides of the pedicle were freed laterally to en-hance its mobility. An adequate window in theauricular cartilage was made to transfer the flap
to the defect anteriorly. The flap and its pediclewere gently passed through the cartilage win-dow. Transfer was either by folding or twistingthe pedicle on its longitudinal axis to bring theskin paddle into position without any tension ordistortion. The skin paddle was then tailoredto match the exact shape of the defect. Thisinvolved trimming the distal tip of the ellipseand the edges of the flap as necessary (Figs. 1through 3).
The revolving door flap was performed asoriginally described by Masson13 and used fordefects of the concha, of the scapha up to thefossa triangularis, or of the external ear canal.4,14
The skin paddle was centered on the auriculo-cephalic groove. The skin island was plannedhalf on the mastoid and half on the medialauricular surface. The flap size was large enoughto allow its edges to comfortably reach and insetinto the defect. The skin was incised and liftedup all round the flap, leaving the subcutaneouspedicle intact at the auriculocephalic groovelevel. Revolving door flaps were transferred tothe defect on the anterior surface of the earthrough the cartilage window by a forward tilt of
Fig. 3. Inferiorly based twisted deepithelialized skin pedicle posterior auricular flap. (Left) Right ear: cutaneous melanoma of theantihelix with 1-cm margins of excision. (Center) Deepithelialization of the skin pedicle and skin paddle (3.4 � 2.7 cm). (Right)Satisfactory result at 6-month follow-up, after flap transfer to the anterior auricular surface through a cartilage window.
the skin paddle on the auriculocephalic axis(Figs. 4 and 5).
Propeller flaps were used in our series for de-fects located at the helical root. Compared withthe revolving door flap, the subcutaneous pedicle
of the propeller flap was eccentrically located atthe proximal end of the skin paddle and the skinpaddle itself was an ellipse; the flap was transferredto the defect by up to 120 degrees of rotation onthe subcutaneous pedicle (Fig. 6).
Fig. 4. Subcutaneous pedicle posterior auricular revolving door flap. (Left) Basal cell carcinoma of the left tragus and excisionmargins. (Center) Posterior auricular revolving door flap design. (Right) Satisfactory result at 2-month follow-up, after flap transferto the anterior auricular surface.
Fig. 5. Subcutaneous pedicle posterior auricular revolving door flap. (Left) Left ear: basal cellcarcinoma of the inferior crus and excision margins. (Right) Aesthetic result at 3-month fol-low-up after subcutaneous pedicle flap transfer.
Transposition Posterior Auricular FlapTransposition flaps were marked at the auricu-
locephalic groove as standard skin pedicle flapseither superiorly or inferiorly based. The distalhalf of the flap was raised relatively thinner thanthe proximal part of the flap (pedicle). No par-ticular attention was paid to include branches orperforators of the posterior auricular artery intothe pedicle base. The flap was transferred to the
defect as a standard transposition flap. The donor-site defect was closed directly. Transposition flapswere designed as bilobed flaps when defects wereparticularly large.
completely excised in this series (98 percent), withadequate margins. One patient, with incompletemargins, presented an early recurrence of his in-filtrating basal cell carcinoma, which was reex-cised. None of the four cases of chondrodermatitisnodularis helicis recurred in our series at a meanfollow-up of 18 months.
Reconstruction was performed in 27 cases withdeepithelialized skin pedicle posterior auricularflaps either superiorly or inferiorly based. Nine-teen patients underwent reconstruction with sub-cutaneous pedicle posterior auricular flaps. Ofthem, 16 were revolving door flaps and three were
propeller flaps; the remaining 11 cases were pos-terior auricular transposition flaps, either simpleor bilobed (Table 3). The donor site was closedprimarily in all cases.
Fifty-four flaps survived completely (95 per-cent). Two transposition flaps suffered tip ne-crosis; this was in part attributed to sharp bend-ing of the flap tip over the auricular cartilagehelical rim. In another case, a pressure necroticarea occurred in the center of the flap, whichhealed conservatively; this was probably pro-voked by the sharp edge of the cartilage. Amongthe flaps that survived completely, eight sufferedfrom temporary venous congestion, which set-tled over a 2- to 4-day period (Table 4).
Aesthetic outcome was considered satisfac-tory in 53 patients (93 percent). Four aestheticunsatisfactory results are worth mentioning: twocases were related to loss of antihelical defini-tion consequent to partial cartilage removal. Inthese cases, no further corrective procedure wasperformed. In the other two cases, the unsatis-factory result was related to the flap reconstruc-tion: in one case, tethering of a revolving doorflap used to cover a large scaphoid fossa andinferior crus anterior defect; in the last case, asuperiorly based transposition flap, compli-cated with tip necrosis and treated conserva-tively, resulted in a notch-like appearance of thehelical rim. These latter two patients refusedfurther correction.
A reconstructive algorithm for anterior ear de-fects followed the review of the clinical series. Dif-ferent posterior auricular flaps were assigned toeight anatomical regions (Fig. 7).
Table 3. Results of Different Flap Types Used in theSeries
Flap Type No.
Superiorly based folded deepithelializedskin pedicle 7
Superiorly based twisted deepithelializedskin pedicle 6
Inferiorly based folded deepithelializedskin pedicle 8
Inferiorly based twisted deepithelializedskin pedicle 6
Revolving door flap 16Propeller flap 3Superiorly based transposition flap 6 (2 bilobed)Inferiorly based transposition flap 5
DISCUSSIONReconstruction of partial defects of the ear,
without reducing the size and without altering thenatural shape, is a challenge. Alternatives to flapreconstruction are spontaneous healing, skingrafts, and wedge excisions that reduce the auric-ular height.
Although the preauricular flap was intro-duced very early in Sushrutha’s description ofcheek flap for lobule reconstruction, the use ofthe area behind the ear as a donor site is rela-tively recent. Brown and Cannon in 194615 firstused this postauricular or auriculomastoid areaas a donor site for free skin and composite grafts.This was quickly followed by a series ofreports16,17 of harvesting postauricular flaps forstaged partial and total reconstruction of theear. Owens18 introduced in 1959 the concept oftransposing the postauricular flap to the otherside of the ear through a window in the cartilagewith a buried deepithelialized pedicle.
The posterior auricular area has become afavored donor site for full-thickness skin grafts,local flaps, regional flaps, and free flaps in facialreconstruction. The popularity of this area as adonor site is mainly attributed to its low mor-bidity, hidden scars, allowance for direct donor-site closure, good skin match to the ear andother facial areas, and its rich vascularization.19
Although the posterior auricular flap was drawnin many different ways, none of them was ableto cover all defects in different sites on thesurface of the auricle. Good planning of theseflaps and the knowledge of advantages and lim-itations of each one of these designs are funda-mental for achieving satisfactory aestheticoutcomes.
Some authors have considered the posteriorauricular flap as an axial flap based on one of themajor divisions of the posterior auricular artery.10
In our series, posterior auricular flaps were har-vested on a random pattern and tailored to reachalmost any site of the ear.
CONCLUSIONSThe posterior auricular flap is the most versa-
tile option for partial ear defect reconstruction.The key to achieving good aesthetic results is tochoose the appropriate design. Our algorithm,together with the proposed techniques, provide asimple approach for reconstructing any given par-tial ear defect.
CODING PERSPECTIVEThis information prepared by Dr. RaymondJanevicius is intended to provide codingguidance.
15576 Formation of direct or tubedpedicle, with or without transfer;eyelids, nose, ears, lips, orintraoral
• The posterior auricular flap is a nonadja-cent, random-pattern flap. Code 15576 de-scribes the formation and straightforwardtransfer of a nonadjacent flap.
• Unusual maneuvers, such as de-epithelializa-tion, creation of an island, excision of carti-lage for transfer, and transaural transfer, areseparately reportable. Since these maneu-vers are a “further reconstructive effort,” thecomplex repair code, 13151, is reported.
• Some payers may incorrectly overbundle thecomplex repair into the flap code; use mod-ifier -59 to indicate that this is a separateprocedure not considered part of the flapcode, 15576.
• Code 15576 does not include tumor resec-tion, which is separately reportable withcode 1164X, selected by the size of theresection.
• The posterior auricular flap is not an ad-jacent tissue transfer, so code 14060 is notappropriate here.
• Until 2010, this “island flap” would be re-ported with code 15740, which took intoaccount the elevation and transfer of theflap and creation of an island of skin byde-epithelialization. As of 2010, code 15740can only be used for an axial pattern islandflap, so it is not appropriate for the random-pattern posterior auricular flap.
3. Renard A. Postauricular flap based on a dermal pedicle forear reconstruction. Plast Reconstr Surg. 1981;68:159–164.
4. Jackson IT, Milligan L, Agrawal K. The versatile revolvingdoor flap in the reconstruction of ear defects. Eur J Plast Surg.1994;17:131–133.
5. Dean Ferrer A, Alamillos Granados FJ, Velez Garcıa-Nieto A,Fernandez Sanroman J. Reconstruction of the scaphoid fossaof the ear after tumour resection with a retroauricular flap.Br J Plast Surg. 1994;47:285–287.
6. Talmi YP, Horowitz Z, Bedrin L, Kronenberg J. Auricularreconstruction with a postauricular myocutaneous islandflap: Flip flop flap. Plast Reconstr Surg. 1996;98:1191–1199.
7. Yotsuyanagi T, Nihei Y, Sawada Y. Reconstruction of thedefects involving the upper one-third of the auricle. PlastReconstr Surg. 1998;102:988–992.
8. Lynch J, Mahajan AL, Regan P. The trap door flap for re-constructing defects of the concha. Br J Plast Surg. 2003;56:709–711.
9. Reddy LV, Zide MF. Reconstruction of skin cancer defects ofthe auricle. J Oral Maxillofac Surg. 2004;62:1457–1471.
10. Park C, Shin KS, Kang HS, Lee YH, Lew JD. A new arterialflap from the postauricular surface: Its anatomic basis andclinical application. Plast Reconstr Surg. 1988;82:498–504.
11. Kolhe PS, Leonard AG. The postauricular flap: Anatomicalstudies. Br J Plast Surg. 1987;40:562–569.
12. Tanzer RC. Postauricular flap based on a dermal pedicle for earreconstruction (Discussion). Plast Reconstr Surg. 1981;68:165.
13. Masson JK. A simple island flap for reconstruction of conchahelix defects. Br J Plast Surg. 1972;25:399–403.
14. Papadopoulos ON, Karypidis DK, Chrisostomidis CI, Kono-faos PP, Frangoulis MB. One-stage reconstruction of theantihelix and concha using postauricular island flap. Clin ExpDermatol. 2008;33:647–650.
15. Brown JB, Cannon B. Composite free grafts of two surfacesof skin and cartilage from the ear. Ann Surg. 1946;124:1101–1107.
16. Lewin ML. Formation of helix with postauricular flap (1946).Plast Reconstr Surg. 1950;5:432–440.
17. Crikelair GF. A method of partial ear reconstruction foravulsion of the upper portion of the ear. Plast Reconstr Surg.1956;17:438–443.
18. Owens N. An effective method for closing the external auditorycanal. Plast Reconstr Surg Transplant Bull. 1959;23:381–387.
19. Cordova A, D’Arpa S, Pirrello R, Giambona C, Moschella F.Retroauricular skin: A flaps bank for ear reconstruction.J Plast Reconstr Aesthet Surg. 2008;61(Suppl 1):S44–S51.
