Received: 22 November 2016 | Revised: 11 January 2017 | Accepted: 17 March 2017

DOI: 10.1002/micr.30178

CLINICAL ARTICLE

More than just the helix: A series of free flaps from the ear

Patrik Lassus, MD, PhD | Annastiina Husso, MD | Jyrki Vuola, MD, PhD |
Andrew J. Lindford, MBBS, PhD

Department of Plastic Surgery, To€o

€ lo
€
Hospital, Helsinki University Hospital, Aim: We herein present our experience using free flaps harvested from the ear region in facial,
University of Helsinki, Finland nasal and intraoral reconstruction.
Correspondence
Patients and Methods: Between 2011 and 2016, 19 patients underwent reconstruction using 20
Patrik Lassus, Department of Plastic
Surgery, To€o
€ lo
€ Hospital, Helsinki University free flaps from the ear region based on the superficial temporal vessels. There were 10 males and
Hospital, Topeliuksenkatu 5, P.O. Box 9 females with a mean age of 57 years. Defect aetiology consisted of post-tumour ablation
00029 HUS, Helsinki, Finland. (n 5 15), trauma (n 5 2) and burn scar (n 5 2). Defect location involved the nose (n 5 13), floor of
Email: [Link]@[Link]
mouth (n 5 3), tongue (n 5 1), lower eyelid (n 5 1), and lower lip (n 5 1).

Results: Twelve helical, seven temporal artery posterior auricular skin (TAPAS), and one hemiauric-
ular flap were performed. One patient required venous re-anastomosis but complete flap necrosis
eventually occurred. This patient later underwent successful contralateral helix flap reconstruction.
Overall flap survival was 95%. Follow-up ranged from 12 to 69 months. A moderate to excellent
aesthetic and functional outcome was achieved in all cases, but most (13/19) required later minor
refinement surgery.

Conclusion: As a versatile source of free flap options, the ear can provide more than just the helix.

1 | INTRODUCTION reconstruction, excessive bulk in intraoral reconstruction and the

requirement of multiple stage operations in nasal reconstruction. In
Defects affecting the nasal region, facial skin and intraoral cavity are particular, regions such as the lower eyelid, lip, or floor of the mouth
exacting in their demands for tissue that can provide a good aesthetic necessitate reconstruction with a thin and pliable flap.
and/or functional result (Menick, 1998). Facial skin and nasal defects The ear, although anatomically a small region, can offer more than
warrant reconstruction with like-for-like tissue in order to achieve an one type of free flap. The first free helical flap was described over 30
adequate aesthetic outcome. Only local flaps can usually meet this years ago by Parkhouse and Evans (Parkhouse & Evans, 1985) and later
demand but are disadvantaged by their visible donor site scarring and popularised by Pribaz and Falco (Pribaz & Falco, 1993). Since then its
moreover, may not be available. Nasal reconstruction in particular, pro- use has increasingly been described in the literature (Dabernig, Ampo-
vides a challenge, and since the earliest report of the use of the fore- mah, & Watson, 2008; Li et al., 2006; Oh, Jeon, & Koh, 2011; Ozek,
head flap in ancient India, a variety of modifications and other local and Gundogan, Bilkay, Alper, & Cagdas, 2002; Ozek, Gurler, Uckan, & Bil-
pedicled flaps have been described (Bakhach, Conde, Demiri, & Baudet, kay, 2007; Shenaq, Dinh, & Spira, 1989; Shimizu, Oatari, & Uehara,
1999; Correa, Weathers, Wolfswinkel, & Thornton, 2013; Orticochea, 2015; Tanaka, Tajima, Tsujiguchi, Fukae, & Ohmiya, 1993; Zhang et al.,
1971; Tollefson & Kriet, 2005; Yoon, Benito-Ruiz, García-Díez, & 2008 ). The attributes of the ascending helix in providing remarkably
Serra-Renom, 2006). However, the latter usually require multiple similar tissue anatomically and aesthetically to the nasal-alar region are
stages and often result in suboptimal aesthetics due to the failure in well recognised.
recreating the subtleties of nasal anatomy. Intraoral defect reconstruc- Following our early experience using free helical flaps for nasal
tion similarly requires a close attention to three-dimensional anatomical reconstruction we discovered a new free flap, the temporal artery pos-
form with only limited local flap options. The facial artery musculomu- terior auricular skin (TAPAS) flap which is based on the same superficial
cosal (FAMM) flap (Pribaz, Stephens, Crespo, & Gifford, 1992) is one temporal (ST) vascular axis and incorporates skin from the retroauricu-
such local option but can only provide a small amount of tissue. lar region. We have recently reported its use in facial and intraoral
Free flaps from distant sites however, are often problematic reconstruction (Lassus & Lindford, 2016). In addition, we have per-
in regards to their poor skin colour match and texture in facial formed an extended auricular or ‘hemiauricular’ flap for subtotal nasal

Microsurgery. 2017;1–10. [Link]/journal/micr V

C 2017 Wiley Periodicals, Inc. | 1
2 | LASSUS ET AL.

reconstruction. This flap included up to half of the ear and was based was planned to run 5-mm behind and parallel to the auricular rim. The
solely on the ST vascular pedicle. posterior flap margin was located over the posterior auricular skin. The
In this report we present the clinical data, surgical procedures and cranial limit was the helical attachment to the temporal skin and the
follow-up results of 19 patients who underwent reconstruction with caudal limit was the termination of the concha at the mastoid process.
20 free flaps from the ear region. Pedicle dissection proceeded in a similar fashion to the helical flap with
a preauricular incision and identification and dissection of the ST ves-
2 | PATIENTS AND METHODS sels. At and above the helical notch, the subcutaneous tissue was pre-
served around the pedicle to ensure capture of all the branches
Between January 2011 and April 2016, nineteen patients underwent supplying the flap. The fasciocutaneous flap was then raised in the ret-
microsurgical reconstruction with 20 free flaps harvested from the ear roauricluar sulcus and at the distal margin the posterior auricular artery
region. The patients were treated and followed-up in the Department was ligated. Small perforators to the cartilage were divided by bipolar
of Plastic Surgery, Helsinki University Hospital. All oncological patients diathermy. Flap dissection proceeded cranially towards the pedicle in a
were evaluated pre-operatively by the relevant (Skin Cancer or Head & plane superficial to the conchal perichondrium and deep temporal fas-
Neck) multidisciplinary tumour board. Ten patients were male and nine cia. Near the helical root the dissection was maintained tightly to the
female. The mean age was 57 years, with an age range of 21–81 years. cartilage in order to safeguard the vascular branches to the flap. The
Defect aetiology comprised post-tumour ablation (n 5 15), trauma retroauricular defect was closed directly when possible.
(n 5 2) and burn scar (n 5 2). A primary reconstruction was performed
in 11 cases. Defect location consisted of predominantly the nasal 2.1.3 | Hemiauricular flap
region (n 5 13) and the remainder comprised of the floor of mouth For one case of subtotal nasal reconstruction an extended “hemiauricu-
(n 5 3), hemi-tongue (n 5 1), lower lip (n 5 1), and lower eyelid (n 5 1). lar” flap was raised (Figure 3). This included 2.5 3 10 cm2 of preauricu-
Four of the 19 patients had earlier undergone local flap reconstruction lar skin, 3 cm of the superior helix, the helical root and part of the
with poor aesthetic outcome (Table 1). concha, the tragus and part of the lobulus. The flap was raised in a sim-
ilar fashion to a helical flap but with the additional preservation of the
2.1 | Surgical technique soft tissue between the ST pedicle and ear thereby preserving the small
tragal and lobular vascular branches. The donor site was reconstructed
2.1.1 | Helical flap
with an advancement of the remaining lateral part of the ear.
The contralateral ear was used for nasal alar defects with the flap
planned to include the root of the helix and adjacent preauricular skin
3 | RESULTS
(Figure 1). The proximal end of the superficial temporal (ST) vessels
provided the pedicle. The helical rim shape and vessel orientation
Twenty free flaps were performed and consisted of 12 helical flaps
enabled optimal insetting for contralateral nasal alar defects. Initially, a
(including a combined helical and hair-bearing scalp flap), 7 TAPAS flaps
preauricular incision was made down to the lobule and the ST vessels
(including a combined TAPAS and conchal flap) and 1 hemiauricular
identified and dissected proximally, up to the maxillary branches. If
flap. All flaps were based on the ST vessels. Flap and defect size ranged
needed, the incision was extended to the temporal hairline to assist
from 25 3 30 mm to 40 3 100 mm (hemiauricular flap). Mean pedicle
vessel exposure. Pedicle dissection then continued in a cranial (distal)
length was 56 mm for the helical and hemiauricular flaps and 59 mm
direction and small branches supplying the tragus were ligated. Near
for the TAPAS flap. In nearly all (19/20) cases, the anterograde ST ves-
the commencement of the helical root, all the subcutaneous tissue
sels were used.
between the ST vessels and helical flap was preserved. This ensured
For nasal reconstruction, the facial vessels in the nasolabial fold
capture of the small branches supplying the flap. More cranially, the
were used as recipient vessels in 13/14 cases. One case required a
distal ends of the ST vessels were ligated unless a longer reverse (retro-
vein graft to the facial artery in the neck. In all five cases of intra-oral
grade) pedicle was desired. The pedicle and the subcutaneous fat were
reconstruction with a TAPAS flap, the pedicle comfortably reached the
then dissected superficially to the deep temporal fascia along an avas-
recipient vessels in the neck. Two patients underwent reconstruction
cular plane. In some cases a branch of the auriculotemporal nerve lying
with a sensate flap by the inclusion of distal sensory branches of the
parallel to the pedicle was included in the flap. The helical flap was
then released from the remainder of the helical rim and root. The heli- auriculotemporal nerve. Mean operation time was 474 min (8 h).

cal rim donor site was reconstructed with an Antia-Buch chondrocuta- Post-operatively, severe venous congestion occurred in three flaps

neous advancement flap and the preauricular wound was closed (1 helical and 2 TAPAS flaps). One patient required venous re-

directly. anastomosis but complete helical flap necrosis nevertheless occurred.

This patient subsequently underwent successful helical flap reconstruc-
2.1.2 | TAPAS flap tion from the contralateral side. Interestingly, the ST pedicle was bilat-
The flap included the nonhair bearing skin behind the ear and was cen- erally anatomically anomalous of small calibre. In the other two
tred over the retroauricular sulcus (Figure 2). Ideally the width of the patients, venous congestion was transient and resolved after 2 days
flap would enable direct donor site closure. The anterior flap margin without intervention. These two patients however suffered a partial
T A B LE 1 Patient demographics, flap, and defect characteristics and clinical outcome

Flap Pedicle
LASSUS

Age/ Primary/ (defect) length Operation Follow-up Final

Sex Flap Diagnosis Defect site secondary size (mm) (mm) Recipient vessels Other time (min) Complications (months) outcome
ET AL.

53/F HELIX BCC Nasal-alar Secondary 35 x 35 55 Facial vessels in Neurorraphy 566 Initial flap swelling 69 Excellent; 3x minor
nasolabial (NL) fold of sensory nerve resolved sponta- corrections
neously

21/F HELIX BCC Nasal-alar- Primary 40 x 40 50 Facial artery at oral 358 Partial skin necrosis 67 Good; 4x minor
nasolabial commissure, Facial corrections
vein in NL fold

55/M HELIX TRAUMA Nasal-alar Primary 40 x 30 80 Facial vessels in NL Retrograde pedicle 489 No 66 Good; 2x minor
fold 1 second arterial also used (parietal corrections
anastomosis to branch of superficial
angular artery near temporal artery)
medial canthus

62/M HELIX TRAUMA Nasal-alar Primary 40 x 20 50 Facial vessels in NL Neurorraphy of 447 No 57 Good; No corrections
fold sensory nerve

62/M HELIX Post-DXT Nasal-alar Primary 30 x 30 80 Facial vessels in NL 345 Initial flap swelling 57 Good; 1x minor
fold resolved sponta- correction
neously

40/ F HELIX 1 hair- BURN Nasal-alar- Secondary 70 x 25 (helix 50 Facial vessels in NL Additional skin flap 480 No 51 Excellent; 3x minor
bearing scalp dorsum flap), 60 x 5 fold containing hair- corrections
& eyebrow (hair-bearing bearing scalp on se-
scalp flap) parate branch of main
pedicle for eyebrow
reconstruction

62/F HELIX BCC Nasal-alar Primary 40 x 30 50 Facial vessels in NL 368 Mild initial flap 43 Excellent; 1x minor
fold swelling correction

58/F HELIX SKIN SCC Nasal Secondary 30 x 35 40 Facial vessels in con- Vessels lacking in 510 Venous thrombosis, 31 Flap loss
columella tralateral NL fold right NL fold due to flap loss, contralateral
previous nasolabial helix flap 4 months
flap, anomalous short later
temporal vessels lying
more deeply

58/F HELIX SKIN SCC Nasal Secondary 25 x 35 70 Facial artery in neck Anomalous temporal 616 No 28 Adequate; 2x minor
columella (salvage) with tunnelled vein vessels, vein found corrections
graft over mandible, more anteriorly
Facial vein in cheek

46/F HELIX BURN Nasal-alar Primary 30 x 50 50 Facial vessels in NL Retrograde pedicle 439 Significant initial flap 22 Good; 2x minor
Fold (parietal branch of swelling resolved corrections
superficial temporal spontaneously
artery)

71/M HELIX BCC Nasal-alar Primary 35 x 50 50 Facial vessels in NL 391 Initial flap swelling 19 Adequate; No
fold resolved corrections
spontaneously
|
3

(Continues)
 4
|

TA BL E 1 (Continued)

Flap Pedicle
Age/ Primary/ (defect) length Operation Follow-up Final
Sex Flap Diagnosis Defect site secondary size (mm) (mm) Recipient vessels Other time (min) Complications (months) outcome

64/M HELIX BCC Nasal-alar Primary 30 x 25 55 Facial vessels in NL 501 Mild initial flap swel- 18 Good; 1x minor
(delayed) fold ling correction

22/F TAPAS TRAUMA Lower Secondary 25 x 50 55 Superficial temporal 485 No 25 Good; 2x minor
eyelid vessels corrections

42/M TAPAS ORAL SCC Floor of Primary 40 x 60 60 Facial vessels in neck 454 Transient venous 20 Good; No corrections
mouth congestion resolved
(FOM) after 2 days. Partial
flap dehiscence re-
quired re-suturing

69/F TAPAS ORAL SCC Lower lip Secondary 25 x 60 60 Superior thyroid ar- 599 No 19 Adequate; 2x minor
tery, Venous branch corrections
of the cervicofacial
trunk in neck

64/M TAPAS ORAL SCC Tongue Primary 40 x 70 60 Facial artery and 462 Delayed auricular do- 16 Excellent; No
thyrocervical vein in nor site healing due corrections
neck to minor helical ne-
crosis

55/M TAPAS 1 BCC Lateral Primary 30 x 40 55 Facial vessels in NL 424 Partial flap dehis- 13 Adequate; 2x minor
CONCHA nose fold cence repaired with corrections
glabellar flap

70/M TAPAS ORAL SCC FOM Primary 35 x 50 60 Facial vessels in neck 570 No 12 Excellent; No
corrections

81/M TAPAS ORAL SCC FOM Primary 45 x 50 60 Facial artery and 448 Marked swelling, 12 Good; No corrections
superior thyroid vein transient venous sta-
in neck sis and partial skin
necrosis

79/ M HEMI- SKIN SCC Subtotal Secondary 40 x 100 45 Facial vessels in NL 531 No 54 Good; 1x minor
AURICULAR nose Fold correction

BCC 5 basal cell carcinoma.

SCC 5 squamous cell carcinoma.
DXT 5 radiotherapy.
TAPAS 5 temporal artery posterior auricular skin (flap).
NL 5 nasolabial.
FOM 5 floor of mouth.
LASSUS
ET AL.
LASSUS ET AL. | 5

FIGURE 1 Helical flap

flap dehiscence requiring resuturing and the other a partial flap necro-
sis. In addition, several flaps had a mild blue colour suggesting relative FIGURE 2 TAPAS flap
flap stasis, but all healed well with no intervention. There was one fur-
ther case of partial flap necrosis and one case of partial flap dehiscence head flap and free cartilage graft was complicated by flap necrosis (Fig-
requiring local glabellar flap closure. Therefore, overall flap survival was ure 4B). One month later secondary reconstruction with a free right
95%. helical flap was performed (Figure 4C,D). Both donor and reconstruc-
Follow-up time ranged from 12 to 69 months. Although a moder- tion sites healed without complications (Figure 4E). Follow-up time was
ate to excellent aesthetic and functional outcome was achieved in all
cases, most (13/19) patients later underwent minor scar corrections
and contouring procedures to further “fine-tune” the overall aesthetic
result. These procedures included scar revisions, flap shaping including
cartilage grafts in some alar reconstructions, and fat grafting.
Three out of 7 TAPAS flaps and one helical flap donor site(s)
required primary retroauricular skin grafting. In one case, a preauricular
flap was used to close the donor site after harvesting a combined
TAPAS and conchal flap. Antia-Buch flap rim advancement was used in
the helical flap cases to achieve a tension-free closure and preservation
of the helical root sulcus. Most auricular donor sites (19/20) healed
uneventfully and in all cases an acceptable aesthetic outcome was
achieved.

3.1 | Case reports

3.1.1 | Case 1
A 52-year-old woman presented with a micronodular basocellular car-
cinoma of the nasal tip (Figure 4A), which was treated primarily with
Mohs surgery. The defect measured 35 3 35 mm2 and involved the
left nasal alar and nasal tip area. Primary reconstruction with a fore- FIGURE 3 Hemiauricular flap
6 | LASSUS ET AL.

FIGURE 4 Helical flap in nasal tip reconstruction. (A) Micronodular basal cell carcinoma in the nasal tip. (B) Result after failed forehead
flap. (C) Flap design. (D) Helix flap. (E) Ear postoperatively. (F) Final result 1 year after touch-up surgery

69 months. The nasal tip and alar lining required 3 minor corrections preauricular skin, 3 cm of the superior helix, the helical root and part of
and an excellent outcome was achieved (Figure 4F). the concha, the tragus and part of the lobulus (Figure 6C,D). The donor
site was closed by advancement of the remaining ear, without recon-
3.1.2 | Case 2 structing the tragus (Figure 6E). Primary postoperative healing was
A 44-year-old male presented with a T2N0M0 tongue squamous cell uneventful and a good outcome was observed at 54 months follow-up.
carcinoma (Figure 5A). Following hemiglossectomy (Figure 5B) and a Only one surgical correction involving removal of excess dorsal nasal
level 1–4 modified radical neck dissection the defect measured 40 3 (flap) skin was required (Figure 6F).
70 mm2 and was immediately reconstructed with a free TAPAS flap
(Figure 5C,D). The postauricular defect was covered with a skin graft 4 | DISCUSSION
(Figure 5E). The postoperative course was uneventful and surgical mar-
gins were confirmed as clear. At 16 months follow-up the patient was Based on its rich vasculature and the ST vascular axis, the ear region
disease-free and the flap was well-healed with no restriction of tongue can provide tissue with unique properties for free flap reconstruction
mobility (Figure 5F). of small to medium sized facial skin, nasal and intraoral defects. Con-
sistent pedicle anatomy and good vessel calibre enabled successful
3.1.3 | Case 3 microsurgical anastomosis in 95% cases. The anatomical basis for these
An 81-year-old male presented with a subtotal nasal defect following flaps is described in the authoritative study by Park et [Link] the arterial
primary resection and radiotherapy of a large nasal squamous cell carci- anatomy of the anterior ear (Park, Lineaweaver, Rumly, & Buncke,
noma 2 years previously (Figure 6A,B). The extensive defect involved 1992).
the nasal tip, complete left alar region and half of the right alar region. Full-thickness nasal defects involving the nasal tip, alae, and colu-
A hemi-auricular flap was raised with a 10 3 4 cm skin island including mella are particularly challenging to reconstruct. Various local and
LASSUS ET AL. | 7

FIGURE 5 TAPAS flap in hemiglossectomy reconstruction. (A) Squamous cell carcinoma of mobile tongue. (B) Hemiglossectomy defect. (C)
Final result after 3 months. (D) Flap design. (E) TAPAS flap. (F) Ear postoperatively

pedicled flaps have been described such as the nasolabial, forehead (n 5 13) is the second largest reported. The smallest nasal defect recon-
(with numerous modifications) and postauricular flaps (Bakhach et al., structed in our series, still measured 30 3 20 mm. Therefore, it has
1999; Correa et al., 2013; Orticochea, 1971; Tollefson & Kriet, 2005; been our practice to reserve free helical flaps for the most challenging
Yoon et al., 2006). Free flaps, such as the radial forearm flap, are disad- of nasal defects when local flap options are neither feasible nor avail-
vantaged by often requiring multiple operations, as they do not provide able. The helical flap is based on the upper auricular branch of the ST
all three anatomical layers, and often struggle to reproduce the precise artery and 4–5 subbranches traverse the ascending helix. Our experi-
anatomical aesthetics of the nasal region. Furthermore, distant free ence revealed mostly constant ST vessel anatomy with consistent
flaps mostly do not provide adequate colour, texture or accurately rep- branches to the ascending helix. One case of bilateral anomalous ST
licate nasal contours (Menick, 1998). Certain segments of the ear share vessel anatomy was however observed (patient 8). On the basis of the
remarkably similar topographical features to the nasal columella and same vascular axis, we included temporal hair-bearing scalp skin in
nostril margin with thin auricular skin tightly adherent to underlying addition to a helical flap for partial eyebrow reconstruction. Hence, this
cartilage, as well as similar colour and texture. Thus composite chon- demonstrates further versatility of the ST axis for providing a further
drocutaneous grafts harvested from the ear, first described in 1914, reconstructive option for hair-bearing skin defects in the facial area.
can provide excellent aesthetic results but are often unsuccessful due The evolution from our use of free helical flaps to the use of the
to their high metabolic demands (Correa et al., 2013). Consequently, TAPAS flap arose from noticing another constant branch given off
the survival of composite grafts diminishes as the graft size increases more cranially, directly from the ST artery, anterior to the helix. This
and is often limited to a maximum of 1 cm graft size (Lehman, Garrett, branch was first described by Song, Song, Qi, Jiang, & Pan (1996), and
& Musgrave, 1971). The use of free helical flaps has thus gained in named the “superior auricular artery.” It measures about 1 mm in diam-
popularity and has been increasingly reported in the literature eter, and runs together with a concomitant vein posteriorly in the
(Bakhach, et al., 1999; Dabernig et al., 2008; Li et al., 2006; Oh et al., groove between the cartilage of the ear and the temporal bone and
2011; Ozek et al., 2002, 2007; Parkhouse & Evans, 1985; Pribaz & anastomoses with the posterior auricular artery. This vessel therefore
Falco, 1993; Shenaq et al., 1989; Shimizu et al., 2015; Tanaka et al., forms the distal pedicle of the TAPAS flap. The potential merits of the
1993; Zhang et al., 2008). To date, our series of free auricular flaps TAPAS flap in facial and intraoral reconstruction have been recently
8 | LASSUS ET AL.

FIGURE 6 Hemiauricular flap in subtotal nasal reconstruction. (A) Squamous cell carcinoma of the nose. (B) Defect 2 years after excision
and radiotherapy. (C) Flap design. (D) Hemiauricular flap. (E) Ear postoperatively. (F) Final result after 1.5 years

described (Lassus & Lindford, 2016). The TAPAS flap can provide tissue auricular artery on both the antero- and postauricular surfaces. In addi-
up to 45 3 70 mm2 with unique characteristics, matching facial skin tion, numerous interconnections exist between both arterial systems via
colour, pliability, and contours. Hence it was effectively used in two perforators piercing the conchal floor (Park et al., 1992). Hence, the ear
cases of lower eyelid and lower lip reconstruction. The TAPAS flap was potentially remains well-vascularised following the sacrifice of either
also used in three cases of FOM reconstruction and one case of tongue arterial system. This is pertinent in view of the harvesting of an
reconstruction following hemiglossectomy. For these small-to-medium extended ‘hemiauricular’ flap. However, the major disadvantage of this
sized intra-oral defects the TAPAS flap can provide suitably pliable and flap is the auricular donor site in which the remaining ear becomes
non-bulky tissue for reconstruction. In addition, there was one case of smaller and more rudimentary in appearance. However, the recon-
lateral nasal reconstruction in which the TAPAS flap was combined structed auricular donor site can be considered acceptable.
with conchal cartilage and anterior conchal skin. The conchal cartilage For all flap types, the initial preauricular incision should at first be
was used for alar reconstruction, the anterior conchal skin for intra- very superficial and a subdermal plane of dissection should proceed
nasal lining, and the posterior auricular skin for outer nasal lining. This anteriorly to avoid injuring the ST vessels. In nearly all cases (19/20),
flap was based on the small perforators piercing the conchal cartilage. an anterograde ST pedicle was dissected and the pedicle length aver-
In addition we herein described a new more extensive flap from aged nearly 6 cm. This is in contrast to the reports by Li et al. and
the ear, the hemiauricular flap, which was used for a one stage subtotal Zhang et al. who advocated the use of the retrograde distal end of the
nasal reconstruction. Several auricular (1–3) branches from the ST ves- ST vessels with potentially longer pedicle lengths (Li et al., 2006; Zhang
sels enable inclusion of different parts of the ear as a flap. These final et al., 2008). In one case we used both an anterograde and retrograde
branches of the ST artery supply the earlobe (lower), tragus (middle) and arterial pedicle.
ascending helix (upper). Latex injection studies have confirmed the col- An earlier study demonstrated that at the upper margin of the auri-
lateralisation of the upper auricular branch to branches of the posterior cle, the outer diameters of the ST artery and vein were 1.7 and
LASSUS ET AL. | 9

2.2 mm, respectively (Park, Lew, & Yoo, 1999). Furthermore, our stand- requisites mandatory for successful reconstruction. Therefore, as a ver-
ard approach when using the ST vessels as recipient vessels is to dis- satile source of free flap options, the ear can provide more than just
sect the vessels proximally to the level of the tragus, ligate the the helix.
maxillary artery and dissect the artery free from the parotid gland. This
results in increased vessel calibre (Vuola, Ohman, & Mäkitie, 2011). R EF ER E N CE S
The thin-walled ST vein was usually located close to the main artery Bakhach, J., Conde, A., Demiri, E., & Baudet, J. (1999). The reverse auric-
and provided good calibre. In most cases one venous anastomosis was ular flap: A new flap for nose reconstruction. Plastic Reconstruction
sufficient. However, in one TAPAS flap case, the posterior auricular Surgery, 104, 1280–1288.

vein (located at the distal end of the flap) proved to be the main drain- Correa, B. J., Weathers, W. M., Wolfswinkel, E. M., & Thornton, J. F.
(2013). The forehead flap: The gold standard of nasal soft tissue
ing vein and provided a second vein for anastomosis. Hence, we sug-
reconstruction. Seminar on Plastic Surgery, 27, 96–103.
gest inspection for and inclusion of any reasonably sized posterior
Dabernig, J., Ampomah, O., & Watson, S. (2008). Nasal tip reconstruction
auricular veins when present. There is also the possibility of a sensate
of the nose with composite ear-helix free flap. Annals of Plastic Sur-
helix flap when a distal branch of the auriculotemporal nerve is incor- gery, 61, 585–586.
porated. This is however best reserved for those cases in which sacri- Haffey, T. M., McBride, J. M., & Fritz, M. A. (2014). Use of angular ves-
fice of the distal nerve is essential for flap harvest or if the branch is sels in head and neck free-tissue transfer: A comprehensive preclini-
adjudged to solely supply flap sensation. cal evaluation. JAMA Facial Plastic Surgery, 16, 348–351.

For nasal reconstruction, the nasolabial facial vessels were nearly Lassus, P. & Lindford, A. J. (2016). Free temporal artery posterior auricu-
lar skin (TAPAS) flap: A new option in facial and intra-oral recon-
always suitable recipient vessels. Even when a local nasolabial flap had
struction. Microsurgery, 9. [Epub ahead of print]
previously been used, vessels in the nasolabial fold could usually be
Lehman, J. A., Jr., Garrett, W. S., Jr., & Musgrave, R. H. (1971). Earlobe
found. It was often necessary to dissect the facial artery proximally to composite grafts for the correction of nasal defects. Plastic Recon-
the oral commissure for improved vessel calibre. A vein graft to the struction Surgery, 47, 12–16.
facial artery in the neck was only required in one case. Several studies Li, S., Cao, W., Cheng, K., Yin, C., Qian, Y., Cao, Y., & Chang, T. S. (2006).
have reviewed the use of the nasolabial facial vessels as recipient ves- Microvascular reconstruction of nasal ala using a reversed superficial
sels (Haffey, McBride, & Fritz, 2014; Oh et al., 2011; Shimizu et al., temporal artery auricular flap. Journal of Plastic and Reconstruction
Aesthetic Surgery, 59, 1300–1304.
2015; Smit, Ruhe, Acosta, Kooloos, & Hartman, 2009; Smit, Hartman,
Menick, F. J. (1998). Facial reconstruction with local and distant tissue:
& Acosta, 2007). Nasolabial vessel nomenclature is variable and terms
The interface of aesthetic and reconstructive surgery. Plastic Recon-
such as “angular vessels,” “nasolabial vessels,” or “nasolabial facial ves- struction Surgery, 102, 1424–1433.
sels” all essentially refer to the same entity. Two anatomical and two Oh, S. J., Jeon, M. K., & Koh, S. H. (2011). Nasolabial facial artery and
clinical studies have corroborated our own experience that these ves- vein as recipient vessels for midface microsurgical reconstruction.
sels can be reliably dissected and are of suitable calibre for microsurgi- Journal of Craniofacial Surgery, 22, 789–791.

cal anastomosis (Haffey, McBride, & Fritz, 2014; Oh et al., 2011; Smit, Orticochea, M. (1971). A new method for total reconstruction of the
nose: The ears as donor areas. British Journal of Plastic Surgery, 24,
Ruhe, Acosta, Kooloos, & Hartman, 2009; Smit, Hartman, & Acosta,
225–232.
2007). The latter two clinical studies also noted the more lateral and
Ozek, C., Gundogan, H., Bilkay, U., Alper, M., & Cagdas, A. (2002). Nasal
deep location of the facial nasolabial vein. A recent report by Shimizu
columella reconstruction with a composite free flap from the root of
et al. advocated the use of the longer retrograde ST pedicle to be anas- auricular helix. Microsurgery, 22, 53–56.
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cosmesis was even achieved in the case of the hemiauricular flap. Pribaz, J. J. & Falco, N. (1993). Nasal reconstruction with auricular micro-
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5 | CONCLUSION
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10 | LASSUS ET AL.

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