Journal Reading

Reconstruction of Defects
of the Posterior Pinna
Neil J. Mortimer, MRCP, Eugene Tan, FACD, and Paul J. M. Salmon, FRACP

Oleh :
Cliff W. Sulangi
Pembimbing :
Dr . A. YulietTamus Sp,THT-KL

Problem
A 69-year-old white man presented for
treatment of a biopsy-proven, poorly defined,
infiltrative basal cell carcinoma of the posterior
aspect of the left pinna.
This was excised with Mohs micrographic
surgery, requiring 2 stages to achieve tumorfree margins. The resultant 2.3 x 2.2 cm defect
involved the lateral aspect of the posterior
pinna but not the helical rim.
Centrally, the defect was devoid of
perichondrium (Figure 1).

How would you reconstruct this

defect?

Resolution
Anumber of reconstructive options
exist for surgical wounds of the
posterior pinna. These include
second intent healing, skin grafting,
and flap repairs.
All have their advantages and
limitations.

In this Case
The authors were concerned about the
protracted course of healing by secondary
intent and the risk of distortion of the ear.
The defect was too large to permit linear
closure, and the exposed cartilage devoid
of perichondrium meant that a skin graft
repair was not ideal.
The authors elected to perform a helical
rim advancement flap (HRAF) to repair
the defect.

HRAF
The HRAF conventionally has been
used as a workhorse flap for the
reconstruction of surgical defects of
the helical rim of the pinna.
However, its utility for defects of the
posterior pinna without involvement
of the helical rim has not previously
been described.

Surgical Technique
The flap was designed and marked.
The surgical defect was extended
anterolaterally to the anterior helical
sulcus. An incision was then made in
the sulcus to the lobule and a
Burows exchange triangle initiated.

 The skin of the posterior surface of

the pinna was then mobilized by
meticulous dissection immediately
above the perichondrium followed by
careful hemostasis by
electrodessication.
This creates the chondrocutaneous
flap based on the skin of the posterior
surface of the pinna.

 Execution of the flap in this way generates

tissue redundancy on the posterior
surface of the pinna, which normally
would be excised but in this case
facilitates the laxity required to close the
surgical defect (Figure 2B).
The flap is then sutured in place using
horizontal mattress sutures at the helical
rim to obtain hypereversion and avoid
notching (Figure 3).

Discussion
The use of HRAFs for defects of the
posterior pinna provides an excellent
cosmetic result, preserves contour of
the helical rim, camouflages incision
lines, and avoids distortion or pinning
back of the cartilaginous framework
of the ear.

Conundrum Keys
Consider the HRAF as a repair option for
carefully selected defects of the posterior pinna
where traditionally the first choice may be a
flap using the tissue reservoir in the region of
the postauricular sulcus.
The ideal surgical defect lies on the
posterolateral aspect of the pinna up to 2 cm in
vertical height.
The posterior ear is highly vascular, and
hematoma formation is a risk. Meticulous
attention to hemostasis is crucial.