BACKGROUND
A common obstacle in the training of dermatologic and
plastic surgery fellows is taking the leap from theory to
practice. While a reconstructive plan may seem forthcoming
and easy to perform when drawn on paper before surgery,
1 the actual surgical procedure encompasses conceptual
and manual difficulties. We are all obliged by the precept of medical
ethics Primum Non Nocere, so how should the novice fellow
begin hands-on training with minimal "damage" to the patient?
Areas of the body that are out of sight, such as the back, are considered
the optimal surgical training sites. Nevertheless, in the
field of reconstructive cutaneous surgery, most reconstructions
take place on the face, which has different tissue characteristics
from those of the back, making the latter inapplicable for many
local flaps. An excellent alternative is reconstruction of helical
rim defects from the postauricular region: tissues in this domain
have similar characteristics to those of other visible areas on the
face, the skin is usually lax and forgiving, less-than-perfect results
are naturally hidden, and complication rates are low,2 making
it an ideal training ground for local flaps.
Reconstruction of Helical Rim Defects: Basic Principles
There is more than one approach toward reconstruction of
helical rim defects. Healing by secondary intention may be reasonable
for select cases in which surgery bears high risk for
the patient, yet secondary healing is a lengthy process that might last 8 weeks or more and exposes the patient to a substantial
risk of infection. Wedge resection and primary closure
is the simplest reconstructive option. In this technique, skin
and cartilage are excised in a triangular shape, after which the
borders are approximated and sutured. It has the advantage of
being the least demanding technique but will result in a certain
extent of asymmetry. While a minimal discrepancy may be
overlooked (as the cliché states: "one can see only one ear at
a time"), noticeable postoperative dissimilarity between ears
is unacceptable and implies poor preoperative assessment. In
addition, unless invaded by tumor cells, cartilage resection is
unnecessary and should be avoided.
Another simple reconstructive solution is a full-thickness skin
graft, assuming the recipient site is appropriate and without
exposed cartilage. A classic postauricular graft is taken from a
donor site that spans the cleavage between the posterior surface
of the ear and the adjacent temporal region (overlying the
mastoid). Finally, reconstruction of helical rim defects can be
done with a wide array of local flaps: advancement, rotation,
transposition, and interpolation flaps,3-6 all of which are based
on postauricular tissues and local blood supply. During the past
5 years, the senior author has documented 61 successful local
flaps based on postauricular tissue: 22 rotation flaps, 17 transposition
flaps (2 bilobed flaps), and 22 interpolation flaps (staged
