This document describes a surgical technique using an anterior pedicled retroauricular flap (APRF) to reconstruct full-thickness defects of the central non-marginal area of the ear. The APRF is harvested from the postauricular skin in two stages and used to reconstruct both the posterior and anterior surfaces of the defect. The procedure was performed successfully in 11 patients to repair conchal defects, with good aesthetic outcomes, minimal donor site morbidity, and high patient satisfaction. The APRF provides an effective method to reconstruct central ear defects while maintaining ear size and shape with minimal stress on the flap.

1. SURGICAL ONCOLOGY AND RECONSTRUCTION
Repairing a Non-Marginal Full-Thickness
Auricular Defect Using a Reversed Flap From
the Postauricular Area
Maria Barbara Heinz, MD, DMD,* Frank H€olzle, MD, DMD, PhD,y
and Alireza Ghassemi, MD, DMD, PhDz
Purpose: Different methods for auricular reconstruction have been introduced over time. To minimize
stress on the flap and offer an excellent wound control, the anterior pedicled retroauricular flap (APRF)
was described in 2012. It offers an excellent alternative for reconstructing different parts of the ear helix.
The authors also apply the APRF to repair centrally located perforating defects of the ear.
Materials and Methods: The APRF was used to reconstruct nonhelical full-thickness defects of the
auricle in 11 patients. The operations were performed under local anesthesia and in an ambulatory setting
in 3 operative steps.
Results: The repair of full-thickness conchal defects was successfully performed in 11 patients, with
good esthetic outcome, minimal donor site morbidity, and high patient satisfaction.
Conclusion: An APRF from the postauricular area is a simple and effective method to reconstruct a full-
thickness non-marginal auricular defect.
Ó 2015 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 73:764-768, 2015
Auricular reconstruction is a challenging interven-
tion that requires esthetic knowledge and surgical
skills. On the one hand, the medical condition
and expectations of the patient are important; on
the other hand, the simplicity and low morbidity
of the technique used are important for successful
rehabilitation.
Although ear reconstruction has been relevant in
facial surgery for nearly 60 years, most methods
have focused on reconstruction of the upper, middle,
or lower third of the ear, including the helical rim,
because most defects are located in these regions.
Reflecting the incidence of such defects, only a few
methods have been described for the centrally
located non-marginal region of the auricle, namely
the concha or the antihelix.1-3
Even fewer have
included the treatment of full-thickness defects in
this region.1
Defects in the central part of the ear
occur infrequently; accordingly, fewer operational
approaches have been developed. Nevertheless,
reconstruction of the central part of the ear is equally
demanding on the surgeon and of great importance
to the patient, especially when considering air
conduction of the ear.4
The triangular fossa and
antihelix are visible portions and they produce
light reflection.2
Even a minor asymmetry in size, shape, color, and
surface can easily affect the overall esthetic appear-
ance of the face and induce psychological distress.5
Because an unreconstructed auricular fossa is prone
to deformity owing to contracture, reconstruction of
this area is indicated.4
This article describes the authors’ technique to
reconstruct full-thickness defects of the central part
of the auricle using an anterior pedicled retroauricular
flap (APRF).6,7
Received from the Department of Oral and Maxillofacial Surgery,
University Hospital RWTH-Aachen, Aachen, Germany.
*Resident.
yHead and Chair.
zConsultant.
Address correspondence and reprint requests to Dr Heinz:
Department of Oral and Maxillofacial Surgery, University Hospital
RWTH-Aachen, Pauwelsstraße 30, 52074 Aachen, Germany;
e-mail: mheinz@ukaachen.de
Received October 13 2014
Accepted November 5 2014
Ó 2015 American Association of Oral and Maxillofacial Surgeons
0278-2391/14/01710-8
http://dx.doi.org/10.1016/j.joms.2014.11.005
764

2. Materials and Methods
From 2010 to 2014, 26 patients (4 women, 22 men;
age range, 25 to 88 yr; mean age, 65.5 yr) with cen-
trally located perforating defects of the auricle were
treated in the authors’ department. The APRF was
used in 11 patients who had developed large defects
of the auricular conchal cavity after surgery
(Table 1). Alternative reconstruction methods were
performed in the other 15 patients.
This study was conducted in compliance with the
World Medical Association Declaration of Helsinki on
medical research protocols and ethics and was
approved by the institutional review board of the Uni-
versity Hospital RWTH-Aachen (Aachen, Germany).
SURGICAL PROCEDURE
A defined area, double the size of the existing defect,
is marked with methylene blue on the postauricular
skin (Fig 1A, B). First, the dorsal area is incised (marked
area I in Fig 1A), elevated, and lifted. The resulting flap
tip is sutured to the anterior tip of the dorsal defect
(Fig 2A, B). Then, the upper and lower margins of
the flap are sutured to the upper and lower borders
of the defect to reconstruct the posterior part of the
lost conchal bowl (Fig 2A). A compression-free wound
dressing is applied.
After a healing period of 2 weeks, the anterior part
of the marked postauricular skin, indicated as area II,
is incised and lifted. Then, the tip of the flap is folded
in an anterior direction on itself to reconstruct the
anterior surface of the conchal cavity (Fig 3). The
upper and lower margins of the flap are sutured to
the upper and lower borders of the anterior defect
side (Fig 4A, B). Subsequently, the hairless skin part
of the flap is used to reconstruct the visible anterior
part of the concha. The defect of the postauricular
area, from which the flap was harvested, is closed pri-
marily after mobilization (Fig 4A). A compression-free
wound dressing is applied.
After another 2-week healing period, the flap is
incised and divided along the transitional part, de-
bulked, and adapted to the lateral border (anteriorly
and posteriorly) as required.
Results
The present technique was performed in 11 cases.
No flap necrosis, noticeable hematoma, or infection
occurred. The overall size of the ear was maintained
in all 11 cases. The skin color, texture, and thickness
of the reconstructed part matched well with the sur-
rounding tissue and fitted well into the overall contour
(Fig 4C). All scars could be placed in a nonvisible re-
gion. No major complications occurred during surgery
or the healing phase. No flap loss was noticed and no
further correction or adjustment was necessary. All pa-
tients expressed their full satisfaction with the result
and reported that no differences could be recognized
by observers.
Discussion
The goal of reconstructive surgery of the auricle is to
reconstruct the ear in an anatomically correct way
with the best possible esthetic outcome while consid-
ering the patient’s medical condition and fulfilling the
patient’s expectations. Maintaining the ear size and
Table 1. SUMMARY OF PATIENTS WITH NON-MARGINAL FULL-THICKNESS EAR DEFECTS TREATED WITH AN
ANTERIOR PEDICLED RETROAURICULAR FLAP
Case Age (yr) Gender Pathology Treated Size of Defect (cm) Location
1 83 M BCC 4 Â 3 antihelix + concha
2 83 M MM 4 Â 3 antihelix + concha
3 76 M SCC 2 Â 1.5 concha
4 82 M CIS 2.5 Â 2 scaphoid fossa
5 71 M BCC 3 Â 3.5 triangular fossa + scaphoid
fossa
6 61 M BCC 2.5 Â 2 scaphoid fossa + tail of antihelix
7 81 F SCC 2.5 Â 1.5 scaphoid fossa
8 77 M BCC 3 Â 2.5 antihelix + scaphoid fossa
9 73 M CIS 1.5 Â 1 concha
10 81 M SCC 3 Â 2.5 scaphoid fossa + triangular
fossa + tail of antihelix
11 82 M BCC 1.5 Â 1 antihelix
Abbreviations: BCC, basal cell carcinoma; CIS, carcinoma in situ; F, female; M, male; MM, malignant melanoma; SCC, squamous
cell carcinoma.
Heinz, H€olzle, and Ghassemi. Postauricular Reversed Flap for Defect Repair. J Oral Maxillofac Surg 2015.
HEINZ, H€OLZLE, AND GHASSEMI 765

3. similarity of the transplanted tissue to the lost tissue
are most important for a successful reconstruction.
Over time different reconstruction methods have
been developed. Most have addressed distinct re-
gions of the ear. Many have involved the repair of
marginal defects,8-13
because the helical rim is an
exposed part of the ear and thus often implicated
in a defect. Moreover, malignant lesions are found
more frequently in this region.14
There are some published techniques that have dealt
with the repair of central nonperforating defects of the
ear,3,4,15-19
such as the subcutaneous island pedicled
graft (flip-flop) flap described by Fader and Johnson15
in 1999, the postauricular flap based on a dermal
pedicle described by Renard16
in 1981, and the 2 bi-
pedicle flaps technique described by Elsahy17
in 2002.
However, for reconstruction of full-thickness defects
in this region, even fewer methods have been
described. One example in the literature is the chondro-
cutaneous advancement flap described by Ramirez and
Heckler,2
which ends up with a decrease of overall ear
size and a modification of the ear shape.
The APRF was developed for the repair of auricular
defects that include the helix.7
The closure of such de-
fects requires only 2 operative steps. A further applica-
tion of this technique is the repair of central auricular
defects. The APRF allows reconstruction of the central
auricle without having to pass the edge of the helix. In
contrast to island flaps,13
the medial and lateral defect
sides are covered with transplanted skin. The anterior
surface of the defect is covered with hairless retroauric-
ular skin. The skin texture, color, and thickness of the
retroauricular skin match the lost auricular tissue. The
donor site can be closed primarily by mobilizing the
FIGURE 1. A, Illustration of a conchal defect and the marked retroauricular skin to design the anterior pedicled retroauricular flap. The flap is
divided into 2 areas, I and II. B, Photograph of a defect of the entire conchal bowl, posterior view.
Heinz, H€olzle, and Ghassemi. Postauricular Reversed Flap for Defect Repair. J Oral Maxillofac Surg 2015.
FIGURE 2. A, Illustration of flap part I after it is elevated, rotated from a posterior to an anterior position, and adapted into the defect area. It is
used to reconstruct the dorsal part of the defect. B, Photograph showing the operative situation, after flap tip I is adapted to cover the posterior
defect side.
Heinz, H€olzle, and Ghassemi. Postauricular Reversed Flap for Defect Repair. J Oral Maxillofac Surg 2015.
766 POSTAURICULAR REVERSED FLAP FOR DEFECT REPAIR

4. surrounding tissue. Because the flap is pedicled anteri-
orly, the tip of the flap is brought closer to the defect
compared with a posterior pedicled retroauricular flap
(PPRF). This is the reason for a tension-free adaptation
of the flap, which cannot be achieved using a PPRF. A
PPRF might continuously bear a dragging force toward
the donor site.4
Although some might consider this an
advantage,4
the wound is exposed to that dragging
force, which can interfere with wound healing and
cause wound dehiscence. In contrast, the present
method offers excellent control of wound healing.
Reconstruction of large auricular defects up to the com-
plete central part can be performed without any labo-
rious postoperative follow-up. Another advantage of
using the APRF is the option of closing the donor area
primarily by surrounding tissue and hiding the resulting
scar in an nonvisible area behind the ear.7
The thick skin
from the retroauricular region provides stability to the
central part of the auricle and obviates insertion of a
cartilage graft on one side or extensive debulking on
the other side. The pedicle of the flap is comparably
broad and then becomes narrower toward the tip,
which insures the blood supply to the tip of the flap.
The design of the flap offers a safe flap vascularization,
without bearing ischemic problems, which can occur
when using island flaps. Moreover, searching for arteries
is unnecessary, which simplifies the procedure.
Despite these advantages, this method still requires
3 surgical steps. Nevertheless, owing to the similar
FIGURE 3. Illustration of the operative situation after harvesting
and transposition of flap part II in the second step. The tip is brought
through the defect to be sutured to the anteromedial tip of the defect.
It covers the anterior surface of the defect.
Heinz, H€olzle, and Ghassemi. Postauricular Reversed Flap for
Defect Repair. J Oral Maxillofac Surg 2015.
FIGURE 4. A, Postoperative view after the second surgery. The donor site area is closed primarily. B, Postoperative photograph directly after
the second surgical step. C, Photograph of the postoperative result 8 weeks after surgery.
Heinz, H€olzle, and Ghassemi. Postauricular Reversed Flap for Defect Repair. J Oral Maxillofac Surg 2015.
HEINZ, H€OLZLE, AND GHASSEMI 767

5. morphology, the esthetic results were excellent and
delivered high patient satisfaction.
The authors conclude that the APRF can be used as
an additional surgical refinement to further optimize
the outcome of reconstructive auricular surgery. The
flap can be used to repair a full-thickness loss of the
central part of the auricle in 3 operative steps while
maintaining the size and appearance of the ear. The
defect of the donor site can be closed primarily and
leaves an invisible scar.
Acknowledgments
The authors thank Mr Wolfgang Graulich from the Institute of
Anatomy, RWTH Aachen, for his contribution in creating the il-
lustrations.
References
1. Elsahy NI: Ear reconstruction with rotation-advancement com-
posite flaps. Plast Reconstr Surg 75:567, 1985
2. Ramirez OM, Heckler FR: Reconstruction of nonmarginal ear
defects with chondrocutaneous advancement flaps. Plast
Reconstr Surg 84:32, 1989
3. Ohsumi N, Iida N: Ear reconstruction with chondrocutaneous
postauricular island flap. Plast Reconstr Surg 96:718, 1995
4. Chen C, Chen ZJ: Reconstruction of the concha of the ear using
a postauricular island flap. Plast Reconstr Surg 86:569, 1990
5. Hyckel P, Robotta C, Schumann D: Partial loss of the auricle:
Multiphase reconstruction and complete preservation of the
helix. Mund Kiefer Gesichtschir 3:131, 1999
6. Ghassemi A, Modabber A, Talebzadeh M, et al: Surgical manage-
ment of auricular defect depending on the size, location, and tis-
sue involved. J Oral Maxillofac Surg 71:232, 2013
7. Stiller MB, Gerressen M, Modabber A, et al: Anteriorly pedicled
retroauricular flap for repair of auricular defects. Aesthetic Plast
Surg 36:623, 2012
8. Butler C: Extended retroauricular advancement flap reconstruc-
tion of a full-thickness auricular defect including posteromedial
and retroauricular skin. Ann Plast Surg 49:317, 2002
9. Goldberg LH, Maulsin DV, Humphreys TR: The postauricular
cutaneous advancement flap for repairing ear rim defects. Der-
matol Surg 22:28, 1995
10. Fata JJ: Composite chondrocutaneous advancement flap: A tech-
nique for reconstruction of marginal defects of the ear. Plast
Reconstr Surg 99:1172, 1997
11. Johnson TM, Fader DJ, Arbor A: The staged retroauricular to
auricular direct pedicle (interpolation) flap for helical ear recon-
struction. J Am Acad Dermatol 37:975, 1997
12. Kaminsky A: Repair of the partial loss of the helix. Aesthetic
Plast Surg 21:427, 1997
13. Lewin ML: Reconstruction of the helix. Arch Otolaryngol 47:
802, 1948
14. Leferink VJ, Nicolai JP: Malignant tumors of the external ear. Ann
Plast Surg 21:550, 1988
15. Fader DJ, Johnson TJ: Ear reconstruction utilizing the subcutane-
ous island pedicle graft (flip-flop) flap. Dermatol Surg 25:94,
1999
16. Renard A: Postauricular flap based on a dermal pedicle for ear
reconstruction. Plast Reconstr Surg 68:159, 1981
17. Elsahy NI: Reconstruction of the ear after skin and perichon-
drium loss. Clin Plast Surg 29:187, 2002
18. Cordova A, D’Arpa S, Pirrello R, et al: Retroauricular skin: A flaps
bank for ear reconstruction. J Plast Reconstr Aesthet Surg 61:44,
2008
19. Mellette JR: Ear reconstruction with local flaps. J Dermatol Surg
Oncol 17:176, 1991
768 POSTAURICULAR REVERSED FLAP FOR DEFECT REPAIR