Reconstruction of upper and lower eyelids with auricular, postauricular, and retroauricular scalping flap with cartilage flap.

Abstract

Sir: The postauricular and retroauricular scalping flap (PARAS), described by Dias and Chhajlani,1 has a profuse circulation from the contralateral superficial temporal vessels. The PARAS flap is described as a skin flap. Our modification adds preauricular skin and a portion of helical cartilage and combines conchal cartilage with postauricular skin. It is called an auricular, postauricular, and retroauricular scalping flap with cartilage flap (APARASC flap) (Fig. 1). Fig. 1. The APARASC flap was elevated. The upper eyelid was reconstructed with the auricular skin and helical cartilage compound flap, and the lower eyelid was reconstructed with postauricular skin and conchal cartilage and retroauricular skin compound flap. A 66-year-old man had developed a tumor on his left cheek 10 years back but received no treatment. The tumor spread slowly and widely and became ulcerated. A biopsy revealed basal cell carcinoma. The ulcerative lesion spread to the upper and lower eyelids. CT scan and MRI showed no cervical metastatic lymph nodes or other metastatic lesions. The ulcerative cancer was resected with a 10-mm tumor-free margin in the cheek and a 5-mm margin in each eyelid. A 15-mm-wide full-layer defect resulted in the upper eyelid and a 20-mm-wide full-layer defect in the lower eyelid. The APARASC flap was elevated. The upper eyelid was reconstructed with the auricular skin and helical cartilage compound flap and the lower eyelid with the postauricular skin and conchal cartilage and retroauricular skin compound flap (Fig. 1). The cartilage with perichondrium remained exposed without covering to allow mucosal migration. The hair-bearing area of the flap was returned back 15 days after the first operation. The cheek and the donor site of the ear region were reconstructed with full-thickness skin grafts from the medial side of the left upper arm. Later, defatting for flap reduction was performed several times. Two and a half years later, the tumor has not recurred. The patient has not complained of dryness of the left eye and can open and close the left eye very easily (Fig. 2). The donor site of the flap has an acceptable appearance. Fig. 2. Appearance of the flap 2½ y after operation. This patient had full-layer defects of his left upper and lower eyelids. For reconstruction, a malar flap could not be used because the skin tumor had spread widely over his cheek. Dias and Chhajlani1 reported their use of a PARAS flap for reconstruction of the facial skin. In their report, the flaps were used in the reconstruction of the frontal region, the cheek, alar defects (2 cases), and the eyelid. In their eyelid repair, ear cartilage was not used. For our patient, we modified their method. The retroauricular-temporal flap can be used to transfer tissue from behind the ear for reconstruction of limited defects of the nose, cheek, and lower eyelid.2 Washio and coworkers3,4 have shown ample anastomoses between the superficial temporal artery and the retroauricular artery. Guyuron5 reported an eye socket reconstruction using a postauricular fasciocutaneous island flap that provided an adequate amount of skin and soft-tissue bulk for reconstruction of a missing eye socket and orbital tissue.