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Rosi-Schumacher et al. Plast Aesthet Res 2022;9:11 https://dx.doi.org/10.20517/2347-9264.2021.64 Page 5 of 8

Figure 3. 3 Stage tubed bipedicled postauricular flap. (A) Post auricular skin is harvested and tubed on itself while pedicled superiorly
and inferiorly. (B) At 2-3 weeks the inferior limb is transposed, leaving superior pedicle intact. (C) The superior pedicle is then divided
in delayed fashion and the tubed flap is opened and inset into the auricular rim defect. (Reused with permission: Ref. [10] ).

Single pedicled chondrocutaneous composite advancement flaps may be used to reconstruct small defects of
[29]
the helical rim, while bipedicled flaps are more commonly used for defects greater than 1.5 cm . The
technique is similar to the above described in the reconstruction of the upper third. In reconstruction of the
middle ear, the incision will begin at the antihelix or scaphoid fossa and parallel the antihelical fold .
[29]
For partial-thickness defects of the conchal bowl involving the cartilage, the postauricular island “flip flop
flap” or modified pull-through flap can be utilized for reconstruction [30-33] . The flap is based on the posterior
auricular artery and designed over the postauricular crease, in the same size as the conchal defect . The
[30]
flap is raised over the pinna in a subperichondrial plane from lateral to medial stopping before the
postauricular crease, at which point the portion of the flap over the mastoid is incised . Depending on
[33]
demands for thickness, the posterior auricular muscle can be harvested in part with the flap. Flap elevation
is from posterior to anterior. Superior and inferior incisions are made to elevate the island, with
preservation of the posterior auricular artery blood supply in the postauricular crease . An opening in the
[31]
defect through the posterior aspect of the conchal bowl is made to allow entrance of the island flap, which is
transposed and anteriorly rotated 180 degrees . The donor site is closed primarily with local tissue
[30]
advancement.

Single stage reconstruction can also be carried out by use of the neighboring postauricular skin over a
conchal cartilage framework. This method works well if there is no antihelix or superior crus defect and the
defect involves less than half of the earlobe or less than 1 cm of the upper auricle . Structural support for
[34]
the reconstruction is provided by conchal cartilage or cartilage harvested from the rib. A bipedicle skin flap
is created by undermining the postauricular and mastoid skin adjacent to the auricular defect, which is then
shaped into a tunnel and positioned to cover the cartilaginous framework .
[34]

DEFECTS OF THE LOWER THIRD
Skin defects of the lobule are subject to deformity and scar contracture if repaired with skin grafting alone.
Total lobule defects should be repaired in multiple stages . Ear lobe reconstruction can be accomplished
[22]
using shaped conchal cartilage. A vascularized skin flap can be raised, forming a subcutaneous pocket
inferior to the auricle at the location of the desired new lobule . The cartilage graft is placed inside, and the
[26]
inferior aspect of the existing ear is sutured to the pocket. At the second stage, the cartilage and overlying