RECONSTRUCTIVE CONUNDRUM

Tragus Reconstruction after Tumor Excision with Preauricular

Folded Flap
NETA ADLER, MD, RON AZARIA, MD, AND DEAN AD-EL, MD

T wo patients with a defect of the tragus

area, after excision of a basal cell carcinoma
under frozen section control, were operated on
82-year-old man. Neither patient
smoked.

in our department during 2005. The first patient Both patients had full-thickness tragal defect ex-
was a 66-year-old woman with a history of tending to the pretragal area (Figure 1). How would
diabetes and the second patient was an you manage this wound?

Figure 1. Postexcision defect of the tragus area.

All authors are affiliated with the Department of Plastic Surgery, Rabin Medical Center, Beilinson Campus, Petah Tiqva
and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

& 2007 by the American Society for Dermatologic Surgery, Inc.
Published by Blackwell Publishing

ISSN: 1076-0512
Dermatol Surg 2007;33:723–726
DOI: 10.1111/j.1524-4725.2007.33150.x

723
 TRAGUS RECONSTRUCTION AFTER TUMOR EXCISION
Figure 2. Flap design and dimensions: a ¼ a; b ¼ b þ c  2.
Resolution
The tragus and pretragal depression are one of the
many fine components of the normal ear. The tragus
holds aesthetic importance, as its distortion or
absence creates an unnatural appearance of con-
tinuity of the cheek and ear. It also serves a minor
functional role as a protective hooding for the
external meatus.1
The aesthetic importance of the tragus presents
itself especially in two situations in plastic
and reconstructive surgery: (1) tragus
reconstruction is part of ear reconstruction in
microtia2–4 and (2) many techniques exist
in rhytidectomy incisions to try to avoid tragus
distortion.1
A less common presentation of the need to recon-
struct the tragus is after local tumor excision
such as basal cell carcinoma or squamous cell
carcinoma. Although many techniques of tragus
reconstruction in microtia are described,2–4 there is
only one report in the medical literature of such
724 D E R M AT O L O G I C S U R G E RY
Figure 3. Elevation of the flap and its rotation laterally.
reconstruction after tumor excision based on the
patient’s earlobe.5
In our patients the tragus was reconstructed in a
single-stage procedure with preauricular flap. The
flap can be superiorly based, as in our cases, or
inferiorly based. It is designed as a transposition flap.
The medial limb should begin at the upper aspect of
the defect and extend along it. The lateral limb
should begin at the same height and finish hidden in
the preauricular wrinkle (Figure 2). The distance
between the medial and lateral limbs of the flap (flap
width) should be about the length of the defect
(Figure 2, a ¼ a), although a slightly narrower flap
should be as effective. It is important to make sure
that the donor site can be closed without tension to
avoid an unacceptable scar. This can be checked by
using a pinch test. If there is tension, the adjacent
cheek should be undermined.
The flap length can be slightly less than the defect
width plus double the width of the planned tragus.
The size of the reconstructed tragus can be deter-
mined by measuring the contralateral one (Figure 2,
b ¼ b þ c  2).

Figure 4. Folding of the flap.
The flap is raised distally to proximally in the
subdermal layer. Its thickness should be greater near
the base to include 2 to 3 mm of subcutaneous tissue
to ensure adequate blood supply. Then the flap is
rotated laterally (Figure 3) and folded onto itself
(Figure 4). Before folding of the flap, an absorbable
suture can be passed from the subcutaneous tissue in
the pretragus area to the flap lying above it, in order
to create a pretragus depression. The distal end of
the flap is sutured to the edges of the external meatus
using 5–0 monocril. The donor site is closed primary
with 5–0 nylon.
The preauricular flap is a random pattern
cutaneous flap based on the rich blood supply of
this area. Perfusion of the preauricular area
is mainly through the superficial temporal
vessels.
The postoperative course was unremarkable except
for some superficial (epidermal) skin sloughing in
one patient which resolved with no treatment
within 1 week. At the 1-year follow-up there
were no wound complications in either patient.
ADLER ET AL
Figure 5. 82-year-old patient, at 1-year follow-up.
Aesthetically we noted good projection of the
tragus, which was even better than that in
the immediate postoperative period even without
cartilage graft for support. The reconstructed
tragus closely resembled the contralateral one
(Figure 5). The scar at the donor site was
well hidden by the preauricle wrinkle. Both
patients reported satisfaction with the
results.
Conundrum Keys

Tragus reconstruction techniques have four major
goals:
1. A pretragus depression without continuity of
the cheek and ear.
2. Good tragus projection.
3. Hidden external meatus.
4. Inconspicuous donor site scar.
33:6:JUNE 2007 725
 TRAGUS RECONSTRUCTION AFTER TUMOR EXCISION

The preauricular folded flap is a safe and simple
solution for tragus reconstruction after local excision.

Patients with local skin tumors, such as basal or
squamous cell carcinoma, are usually older and have
wrinkles in the preauricular region. Thus, the donor
site scar can be hidden in the natural skin lines.

In men, the preauricular area is usually hairy, and
the flap might include hair follicles. Because the
tragus sometimes grows hair naturally, however,
use of a flap is acceptable.

Although the tragus is composed of soft tissue and
cartilage, and cartilage graft might be considered
for support during reconstruction, good projection
may be achieved without it, sparing patients
additional operative time and potential complica-
tions. It is possible that the contracture of the scar
pulls the reconstructed tragus outward, thereby
creating a projection.
726 D E R M AT O L O G I C S U R G E RY
References
1. Ramirez OM, Heler L. The anchor tragal flap: a method of
preserving the natural pretragal depression during rhytidectomy.
Plast Reconstr Surg 2005;116:1115–21.
2. Tanzer RC. Correction of microtia with autogenous costal
cartilage. In: Edegerton MT, editor. Symposium on
reconstruction of the auricle, Vol. X. St. Louis: Mosby, 1974:
46–7.
3. Brent B. Technical advances in ear reconstruction with autogenous
rib cartilage grafts: Personal experience with 1200 cases. Plast
Reconstr Surg 1999;104:319–34.
4. Nagata S. Modification of the stages in total reconstruction of the
auricle: Part 1. Grafting the three dimensional costal cartilage
framework for lobule type microtia. Plast Reconstr Surg
1994;93:221–30.
5. Martinez JM, Olivares AC, Cimorra GA. Reconstruction of
the tragus after tumor excision. Br J Plast Surg 1997;50:
552–4.
Address correspondence and reprint requests to:
Neta Adler, MD, Department of Plastic Surgery, Rabin
Medical Center, Beilinson Campus, Petah Tiqva 49100,
Israel, or e-mail: amosad@gmail.com