DS13: Taking it to extremes: expanding the utility of the ‘flip-flop flap’ in auricular reconstruction

Hayley Smith and Walayat Hussain

Leeds Teaching Hospitals, Leeds, UK

The postauricular pull-through island flap, commonly referred to as the flip-flop flap (FFF), is a well-established single-stage repair for small defects of the conchal bowl and anterior helix. To date, the published literature on the FFF focuses on cutaneous defects of the ear, in the region of 1–2 cm in diameter, with an intact surrounding cartilaginous framework. We describe our experience of using the FFF in the single-stage reconstruction of a very large surgical defect of the ear, involving significant loss of cartilage. An 82-year-old man underwent Mohs tumour extirpation of a biopsy-proven, morphoeic basal cell carcinoma of the ear. Tumour-free margins were achieved after two stages and four sections. The resultant surgical defect measured 3·5 × 5·5 cm, approximating to two-thirds of the anterior aspect of the ear. Although the postauricular skin was intact, cartilage loss included the scapha, anterior and posterior crus, the majority of the antihelical rim and over two-thirds of the concha. Given the extensive loss of cartilage, a full-thickness skin graft would not have supported the remaining ear and would have prevented our patient from continuing to wear his spectacles due to inevitable graft contraction causing a marked deformity of the ear. We therefore chose to use what remained of the postauricular skin to resurface the anterior ear defect, by creating a full-thickness incision along the inner aspect of the helical rim and ‘flip-flopping’ it forward. The postauricular sulcus was then incised in a precise semi-circular fashion to match the remaining anterior aspect of the ear that required resurfacing, while also ensuring the helical rim contour was supported by the flap, thus obviating the need for any cartilage. Sharp and blunt dissection was performed only as much as required for the FFF to be advanced without tension into place, to maximize the perforating branches of the postauricular artery feeding the base of the flap. The postauricular defect in the sulcus was then sutured in a pinnaplasty fashion using fully absorbable skin sutures. The long-term outcome of the FFF in this very challenging case was very favourable and enabled our patient to continue wearing his spectacles without difficulty. We present the utility of the FFF in reconstructing very large defects of the anterior ear and demonstrate that, with appropriate flap design and execution, the need to replace extensive loss of cartilage may not be required.