A postauricular flap to reconstruct facial defects

A POSTAURICULAR

FLAP TO RECONSTRUCT

FACIAL

DEFECTS

By MIGUELORTICOCHEA, M.D.l Plastic Surgery Division, National Cancer Institute, Bogota, Columbia

MOST natives in Colombia are descended from more than one race and their skins show a wide range of pigmentation. Free skin grafts on their faces give very poor results because of pigment changes in the grafts. On the other hand, flaps do not change colour after transplantation. Postauricular skin is the closest in colour and texture to facial skin and this paper describes how it may be transferred as a pedicled flap to many parts of the face and scalp. The principles involved are those described in my technique of total nasal reconstruction (Orticochea, 1971). The anastomoses of the superficial temporal arteries with each other and with other scalp vessels is so full and free that after suitable delays, the direction of blood flow in them can be completely reversed. The area of hairless 1Former student Pasteur Hospital, Montevideo, Uruguay. Address for reprints: Professor Miguel Orticochea, Apartado Aereo 8224, Bogota, Colombia, America.

FIG. I.

In white people a hairy naevus of this kind is best replaced with a free skin graft. skins, flaps are preferable because of the colour changes in free grafts.

29/4--D

32.5

South

In pigmented

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SURGERY

A POSTAURICULAR

FLAP TO RECONSTRUCT FACIAL

DEFECTS

327

skin available in the flap averages about 47 cm2. An additional advantage of the method is that virtually no scar is visible on the donor site. TECHNIQUE

Stage I. In a typical case, such as shown in Figure I, a 16 x 4 cm strap flap is raised running from the frontal region to the postauricular and mastoid regions. A I cm strip of hairy scalp is included along the posterior border of the postauricular skin to prevent vascular impairment particularly at the level of the upper attachment of the ear (Figs. 2 and 3). The postauricular skin is dissected free with a scalpel at the levels of the auricular cartilage, the periosteum over the mastoid process and the fascia covering the sternomastoid and temporal muscles. The superficial temporal vessels are sectioned at the level of the tragus and transplanted with their surrounding fat to the deep aspect of the postauricular skin. Split skin grafts cover the raw area on the underside of the upper pedicle and its donor site.

FIG.

This flap was too narrow and some necrosis occurred as shown at the junction of the 2 vascular territories: that of the temporal vessels above, that of the post-auricular vessels below.

FIG. 4. FIG.

5.

The pedicle

A and

B, Second

raised delay.

flap is raised. temporal vessels

of the anterior

A and

3.

B, The fronto-postauricular incision, the superficial

Through ab, the lower part are exposed and sectioned.

FIG. 2.

and healed. The

I. Post-auricular

skin.

postauricular skin is raised adherent.

2. Hair only

bearing

upper

as far as zone

pedicle.

2 which

is left

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FIG. 6. The postauricular skin sutured back. During the next week or two its circulation is taken over adequately by retrograde flow in the superficial temporal artery.

The raised postauricular (Fig. 4).

skin is sutured

back; nothing

should be placed under

it

Stage 2. The lower pedicle is delayed 4 weeks later. A 1.5 cm strip is left adherent as shown to maintain circulation in the flap until the retrograde flow in the superficial temporal artery is sufficient to take over (Figs. 5 and 6). Stage 3. Three weeks later the whole flap is raised and transplanted (Fig. 7). The raw surface behind the ear is closed directly by bringing the ear backwards. Stage 4. Finally, the flap (Fig. 8) is detached and the pedicle returned to its donor site 3-4 weeks later. When the flap is divided the retrograde flow from the temporal artery is convincingly obvious. The previously applied split skin grafts must be excised. That on the pedicle will be found to rest on a fibrous membrane. This should not be dissected free because

A POSTAURICLJLAR

FIG.

7.

FLAP

TO

RECONSTRUCT

FACIAL

DEFECTS

A, B and C, The flap raised and transplanted. D, The ear brought postauricular defect.

backwards

329

to close the

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FIG. 8.

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SURGERY

The flap in position and still rather oedematous. FIG. 9.

Final result.

FIG. IO. A and B, Extensive

naevus of nose.

A POSTAURICULAR

FLAP

FIG.

II.

FIG.

TO

RECONSTRUCT

FACIAL

A and B, The plan of the flap.

12.

The flap transposed.

DEFECTS

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FIG. 13. A and B, Postoperative

JOURNAL

result.

OF

PLASTIC

SURGERY

C, There is little scarring to be seen on the donor site.

FIG. 14. The range of sites to which the postauricular

flap may be transplanted.

A POSTAURICULAR

FLAP TO RECONSTRUCT

FACIAL

DEFECTS

333

of the risk of damaging the vessels but may be partially sectioned lengthwise to enable the pedicle to be unrolled. The final result is shown in Figure 9 and another case in which the method was used in Figures IO to 13. SUMMARY

The postauricular skin may be transferred as a pedicled flap by making use of reverse flow in the superficial temporal artery when suitably delayed. The range of the flap is shown in Figure 14.

REFERENCE ORTICOCHEA, M. (1971). A new method of total reconstruction areas. British Journal of Plastic Surgery, 24, 225.

of the nose: the ears as donor