Surgical Corner: Wet Behind the Ears: The Postauricular Training Ground for Local Flaps
November 2012 | Volume 11 | Issue 11 | Features | 1358 | Copyright © November 2012
AbstractEarly in the course of surgical education, dermatologic and plastic surgery trainees shift from theory to practice. This shift must be done cautiously so as not to cause unnecessary damage to the patient, especially when attempting to reconstruct soft tissue defects on the face. Helical rim defects present an excellent opportunity because the postauricular region provides a safe environment for novice surgeons to practice the theoretical and manual aspects of basic flap reconstruction. This paper explains key features on how to plan basic flaps based on postauricular tissues.
J Drugs Dermatol. 2012;11(11):1358-1360.
A common obstacle in the training of dermatologic and plastic surgery fellows is taking the leap from theory to practice. While a reconstructive plan may seem forthcoming and easy to perform when drawn on paper before surgery, 1 the actual surgical procedure encompasses conceptual and manual difficulties. We are all obliged by the precept of medical ethics Primum Non Nocere, so how should the novice fellow begin hands-on training with minimal "damage" to the patient? Areas of the body that are out of sight, such as the back, are considered the optimal surgical training sites. Nevertheless, in the field of reconstructive cutaneous surgery, most reconstructions take place on the face, which has different tissue characteristics from those of the back, making the latter inapplicable for many local flaps. An excellent alternative is reconstruction of helical rim defects from the postauricular region: tissues in this domain have similar characteristics to those of other visible areas on the face, the skin is usually lax and forgiving, less-than-perfect results are naturally hidden, and complication rates are low,2 making it an ideal training ground for local flaps.
There is more than one approach toward reconstruction of helical rim defects. Healing by secondary intention may be reasonable for select cases in which surgery bears high risk for the patient, yet secondary healing is a lengthy process that might last 8 weeks or more and exposes the patient to a substantial risk of infection. Wedge resection and primary closure is the simplest reconstructive option. In this technique, skin and cartilage are excised in a triangular shape, after which the borders are approximated and sutured. It has the advantage of being the least demanding technique but will result in a certain extent of asymmetry. While a minimal discrepancy may be overlooked (as the cliché states: "one can see only one ear at a time"), noticeable postoperative dissimilarity between ears is unacceptable and implies poor preoperative assessment. In addition, unless invaded by tumor cells, cartilage resection is unnecessary and should be avoided.
Another simple reconstructive solution is a full-thickness skin graft, assuming the recipient site is appropriate and without exposed cartilage. A classic postauricular graft is taken from a donor site that spans the cleavage between the posterior surface of the ear and the adjacent temporal region (overlying the mastoid). Finally, reconstruction of helical rim defects can be done with a wide array of local flaps: advancement, rotation, transposition, and interpolation flaps,3-6 all of which are based on postauricular tissues and local blood supply. During the past 5 years, the senior author has documented 61 successful local flaps based on postauricular tissue: 22 rotation flaps, 17 transposition flaps (2 bilobed flaps), and 22 interpolation flaps (staged