Case Competition 2024 – All submitted cases Case 6 Revolving Door Flap
Keywords: Revolving Door Flap, Postauricular Island Flap, Concha reconstruction
Authors: Paula Ejdier (MD), Dogu Aydin (MD). Rigshospitalet, Copenhagen, Denmark
78 year old female referred to Plastic Surgery Department by local ENT-doctor after punch biopsy findings of Squamous cell carcinoma in situ, with questionable stromal invasion on right ear concha. Tumor debut 1 month prior with since fast growth.
Before and after
Patient examination
The patient presents a physical and cognitive well preserved condition. Skin: Clearly visible ulcerated tumor on right ear concha of approx.12x8mm and a central cartilage island of approx.4mm with erosion. Adherent and not displaceable from the underlying tissue. The skin on the back of the ear is intact and without signs of ingrowth. Overall right ear is seen slightly red and swollen (compared to left ear). Very tender when palpated. Lymph nodes: no pathologic lymph nodes were palpable in the region
Pre-Operative Considerations
Squamous cell carcinomas (SCC) present a more aggressive growth pattern compared to Basal cell carcinomas, with a potentially higher risk of metastasis. The tumor of the patient presents a clinical suspicion, as well as in the light of the fast growth and questionable stroma invasion on punch biopsy, of being a SCC rather than SCC in situ. The patient is informed about treatment options in the form of surgery or radiotherapy, as well as the associated advantages, disadvantages and possible complications respectively related. The patient preferres surgery. The patient is planned for an Excision with a 5 mm margin incl. cartilage + perioperative freeze histopathology in order to determine a radical margin before a reconstruction of the defect. Due to the area of surgery, two possible reconstruction methods are considered 1] Revolving Door flap (RD flap) or also known as Postauricular Island flap. 2] Full skin graft, harvested from the e.g preauricular, clavicular or upper arm region. Given the well preserved condition of the aesthetically aware female patient, and in light of an autoimmune precondition, the decision falls upon the local RD flap. Reducing areas of scars, and leaving potential infection risk to only one site.
Step 1: Excision of tumor
Excision area is outlined with a 5mm safety margin. Under local anesthetic (Lidocaine + Adrenalin) para-auricular and locally, the tumor is excised incl. underlying cartilage. Freeze sections are harvested from margin boarders 12, 3, 6, 9 o’clock + the base and send for perioperative rapid histopathology. Analysis show tumor cells 9 o’clock – why further 5mm margin locally in that section of the defect is excised. Thereafter no signs of malignancy are found corresponding to all the margin boarders + base. Reconstruction part can therefore begin.
Step 2: Flap outline
The RD flap is drawn posteriorly with; the ½ circle defined by the remaining retro-auricular skin according to the defect and second ½ circle duplicating the other in size. The midline is defined by the postauricular sulcus.
Step 3: 1.stage Flap elevation: antero-medial defect closure
1.stage: The flap is raised taking into account the blood supply stalked throughout the midline of the flap The medial dermal half is pulled forward, and undergoes a rotational movement (like a revolving door) that changes its position from “postauricular” to “antero-auricular”. Now covering the antero-medial half of the frontal defect.
Step 4: 1.stage Suture
The antero-medial part of the flap is attached superficially using a continuous-suture, Prolene 5-0
Step 5: 2.stage Flap elevation: posterior + antero-lateral defect closure
2.stage: Postauricular lateral dermal half is undermined, only at the edges, and pulled forward through the defect (green). Now in a frontal position, it is then attached to the antihelix. The remaining edges are aligned together posteriorly (blue) recreating a new sulcus line.
Step 6: 2.stage Suture and final Wound dressing
The donorsite posteriorly (left) is closed superficially using a continuous-suture, Prolene 5-0. The antero-lateral part of the flap (right) is attached to antihelix superficially using a continuous-suture, Prolene 5-0. Few supporting single stitches are made here-and-there. Wound dressing: Posteriorly is applied MicroporeM3 on the scar. Anteriorly is applied a sponge to create a compression to the flap and attached by MicroporeM3 (NB no sutures are used to fixate the wound dressing)
Step 7: Follow-up
Wound check 2 weeks after surgery (left). The wound dressings are removed. No signs of irritation, infection nor necrosis. Patient is satisfied. The flap had at no point shown signs of complications. Follow up 3 months after surgery (right). The patient is fully satisfied with the cosmetic result with no reports of functional nor other discomforts.
Post-Operative Plan
Histopathology showed a radically removed SCC infiltrating the perichondrium deeply but not entering the cartilage itself, with no further vascular nor neural ingrowth. The patient is invited for a final clinical 1year follow up and will thereafter be dismissed from our department with a successful outcome.
- Allows cohesion of the flaps skin color with the rest of the external ear.
- Gives less contour defects in a region rich on curves.
- Minimizes; potential infection areas, donor site morbidity as well as conspicuous scar formation.
- Shows several advantages over the skin graft method, which can be prone to a delayed wound healing, pigmentation discrepancy and centripetal contraction with deformation of the concha area.
- Like the ‘revolving door’ concept, the lobe undergoes a rotational movement that shifts from the “postauricular” to the “antero-auricular” surface, along a “vertical axis”. This very axis serves both as a fundamental soft tissue attachment as well as forms the seat of a neurovascular core. Through this core blood supply continues to be provided through an arterial network formed by branches originating from superficial temporal,- and postauricular arteries, in the retroauricular groove.
- In order to secure and prevent a flap necrosis, one should show great respect during flap elevation, in order not to undermine too further deep nor cut across this main important axis core.
References
- Masson JK. A simple island flap for reconstruction of concha-helix defects. British journal of plastic surgery. 1972 Jan 1;25:399-403
- Golash A, Bera S, Kanoi AV, Golash A. The Revolving Door Flap: Revisiting an Elegant but Forgotten Flap for Ear Defect Reconstruction. Indian J Plast Surg. 2020 Mar;53(1):64-70. doi: 10.1055/s-0040-1709531. Epub 2020 Apr 13. PMID: 32367919; PMCID: PMC7192703.
- Iljin A, Antoszewski B, Durko M, Zieliński T, Stabryła P, Pietruszewska W. External ear carcinoma: evaluation of surgical and reconstructive management with postauricular island flap. Postepy Dermatol Alergol. 2022 Dec;39(6):1134-1140. doi: 10.5114/ada.2022.122608. Epub 2022 Dec 22. PMID: 36686011; PMCID: PMC9837570.
- Zhu J, Zhao H, Wu K, Lv C, Bi HD, Sun MY, Wang YC, Xing X, Xue CY. Reconstruction of auricular conchal defects with local flaps. Medicine (Baltimore). 2016 Nov;95(46):e5282. doi: 10.1097/MD.0000000000005282. PMID: 27861353; PMCID: PMC5120910.
