Surgical Conundrum: Transcartilage Island Pedicle Flap for a Scapha Defect

RECONSTRUCTIVE CONUNDRUM

Surgical Conundrum: Transcartilage Island Pedicle Flap for a Scapha Defect STEVEN Q. WANG, MD, LEONARD H. GOLDBERG, MD, FRCP,

AND

ARASH KIMYIA ASADI, MD

The authors have indicated no significant interest with commercial supporters.

A

healthy 55-year-old Caucasian man presented with an infiltrative basal cell carcinoma on the right scapha. Mohs micrographic surgery was per-

formed. Figure 1 illustrates the size of the defect after the first stage of Mohs excision. Basaloid islands of tumors were present in the deep layer, and the

Figure 1. The size of the final defect was 2.5  2.2 cm. The residual tumor and perichondrium were removed after the second Mohs layer, exposing the cartilage.

All authors are affiliated with Dermatology Service, Memorial Sloan-Kettering Cancer Center, DermSurgery Associates,

Houston, Texas & 2009 by the American Society for Dermatologic Surgery, Inc.  Published by Wiley Periodicals, Inc.  ISSN: 1076-0512  Dermatol Surg 2009;35:505–508  DOI: 10.1111/j.1524-4725.2009.01070.x 505

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Figure 2. The donor site in the posterior sulcus area was outlined to match the size and shape of the primary defect. The vertical line marked the site of incision through the cartilage (A). The dotted circle demarcates the location of the donor site viewed from the anterior perspective. There should be a 30% overlap between the donor and defect areas (B). An island pedicle flap was developed after a circumferential excision. The black vertical line demarcates the site of the incision at the cartilage (C). A small strip of cartilage was removed to create the window for the tissue to flip through (D). The flap was pulled through the window with a 1801 flip and secured with a series of 6-0 interrupted Prolene sutures (E).

peripheral edges were cleared. Residual tumor along with perichondrium was removed after a secondstage Mohs excision. The resulting defect was 2.5  2.2 cm with exposed cartilage. How would you reconstruct this defect?

Resolution The final defect was oval and occupied a significant portion of the scapha. The defect was devoid of any perichondrium, exposing the cartilage. A number of repair options were considered. Second-intention

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healing is a time-honored approach. However, in this case, multiple small punch biopsies through the cartilage were needed to expedite granulation from the other side of the cartilage and the healing process. Aside from prolonged healing time, scarring and potential contraction of the wound might have distorted the normal contour, size, and shape of the ear profile. In addition, additional trauma to the cartilage might have resulted in chondritis. An interpolation flap was another viable option. Potential donor sites can come from the preauricular or posterior sulcus sites. The major disadvantage is the need for an additional surgery to sever the pedicle

WA N G E T A L

3 weeks later. The interim period could have been an inconvenience for the patient who had an active social and work life. A full-thickness skin graft was also considered. The viability of a graft lying on the exposed cartilage was not optimal. Lack of underlying vasculature and perichondrium can lead to graft necrosis. After careful consideration, we decided to use a transcartilage island pedicle flap1,2 tunneled from the postauricular sulcus area for the closure. This would expedite the healing process and preserve the size and contour of the ear.

The Procedure Donor skin of the posterior sulcus was outlined to match the size and the shape of the primary defect in the scapha (Figure 2A). The vertical line marked the site of the incision through the cartilage. There was at least a 30% overlap between the defect and donor areas (Figure 2B). Local anesthetic solution with a concentration of 0.5% lidocaine with 1:200,000 epinephrine buffered with sodium bicarbonate was injected into the dermis around the defect and the postauricular donor site. A circumferential incision was made at the donor site of the perichondrium on the ear and into the subcutaneous tissue in the postauricular sulcus. The donor site was further undermined circumferentially beneath the dermis, leaving a central subcutaneous pedicle attached. The flap was attached to a loose, random vascular pedicle (Figure 2C). The black vertical line marks the site of a later incision through the cartilage. A narrow strip of cartilage was removed to create a passage for the donor tissue to tunnel through to cover the defect in the scapha (Figure 2D). If needed, a large strip of cartilage may be removed to successfully execute the flap movement. Instead of pulling the flap through the cartilage, it is ‘‘flipped’’ 1801 through the cartilage. The lateral edge (marked by a star in Figure 2C) of the flap covered the medial edge of the defect, and the medial edge (marked by a circle in Figure 2C) of the flap covered the lateral edge (medial to the helical rim) of the defect. A series of 6-0 Prolene interrupted sutures was used to secure the flap (Figure 2E). The secondary defect in the

Figure 3. The secondary defect is shown at the posterior sulcus.

posterior sulcus (Figure 3) was closed in a sideto-side fashion with a 5-0 Vicryl and a 6-0 Prolene suture. Second-intention healing for the postauricular sulcus defect is also a viable option. The resulting scar or contracture will not be of major cosmetic importance, because the postauricular area is not a visually noticeable site. In this case, the defect was relatively large, and primary closure was used to expedite the healing process. Primary closure or secondary-intention healing can result in some pinning back of the ear, which can be a problem for patients who wear glasses. Secondary corrective procedures such as a retroauricular Z-plasty may be necessary. To prevent potential chondritis, the patient was placed on ciprofloxacin

Figure 4. Clinical appearance of the surgical site 3 months after the repair.

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500 mg daily for 7 days. Figure 4 illustrates the cosmetic outcome at 3 months after the surgery. In summary, we present a repair option to replace tissue for large defects of the scapha. It preserves the normal size and contour of the scapha. In addition, it offers a rapid recovery time for the patient.

Conundrum Keys:  An island pedicle skin flap was developed from the posterior auricular sulcus and used to replace and repair a large portion of the scapha.  The outlined flap area should have at least 30% overlap with that of the defect in the scapha. This overlap makes it easier to flip the pedicle without any tension from advancing the pedicle. A smaller overlap will require the removal of a larger cartilage window to allow the flap to pull through.

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 To reduce pedicle tension, a small strip of cartilage can be removed.  This is a tunneled island pedicle flap. The flap is flipped 1801 through a narrow slit or strip in the cartilage.  The secondary defect in the posterior sulcus can be closed in a side-to-side fashion or allowed to heal by second intention. The resulting scar is well hidden, because the postauricular site is not a visually noticeable area.

References 1. Fader DJ, Johnson TM. Ear reconstruction utilizing the subcutaneous island pedicle graft (flip-flop) flap. Dermatol Surg 1996;25:94–6. 2. Kimyai-Asadi A, Goldberg LH. Island pedicle flap. Dermatol Clin 2005;23:113–27.