PALM DESERT, CALIF. An island pedicle flap can easily be elongated to accommodate facial anatomy and a pedicle graft for the ear's conchal bowl can come from the back of the ear, two dermatologists said in a session titled, "My Favorite Flap" at the annual meeting of the American Society for Dermatologic Surgery.
The island pedicle flap is a modest, undramatic flap that can be used to turn a round defect into a long slim defect that is easy to close, said Dr. David S. Becker, a Mohs surgeon in New York.
It does not, however, always have to be triangular in shape. In locations such as the upper lip or near the eyebrow it can be elongated to avoid creating deformity of facial features such as the vermillion, with two parallel sides before the taper.
In that case, it becomes a pentagonal pedicle, rather than a triangle, he said.
Elongating the taper also can make the defect easier to close, with less tension, he added.
In the right location, this flap rarely fails, and "if you loosen them up properly, they just float into place on a cloud of adipose tissue," Dr. Becker said.
Dr. Arash Kimyai-Asadi said that he repairs surgical defects of the front of the ear by taking a pedicle flap from the back, which he then threads through a small slit made through the cartilage.
This transcartilage, tubed, pedicle flap, as he has named it, works particularly well for defects in the conchal bowl, the triangular fossa, and the antihelix, said Dr. Kimyai-Asadi, who practices Mohs surgery in Houston.
It solves the problem of closing defects in the ear, where there is not a lot of loose skin, and he has used it to close defects 3 cm in diameter.
He said he has done 31 cases so far and has had no need for revisions, though because of swelling in the concha he has injected triamcinolone a few times.
The flap "works so well, I am using it for smaller and smaller defects now," he added. The ideal defect for the approach is one that is about 1 cm in diameter.
He makes the flap from skin on the back of the ear close to the postauricular sulcus. Then he makes what is usually a 4-mm wide incision through the cartilage, through which the pedicle flap is threaded. It is then sewn into place, and the pedicle defect is closed.
"It is a very vascular area, so you don't need a large pedicle," he said.
Because the skin matches well, "most of the time, they are very difficult to see post op," he noted.
The flap is threaded from the posterior ear through a slit in the cartilage.
The flap is shown being put into place over the defect. Photos courtesy Dr. Arash Kimyai-Asadi