DERMATOLOGIC SURGERY

The utility of full-thickness skin grafts (FTSGs)

for auricular reconstruction
Joshua W. Trufant, MD,a Sean Marzolf, MD,b Brian C. Leach, MD,b and Joel Cook, MDb
Philadelphia, Pennsylvania, and Charleston, South Carolina

Background: Full-thickness skin grafts (FTSGs) are a common repair option on the external ear, but there
are few large case series examining graft sublocations, dimensions, and outcomes.

Objective: We sought to report our experience with FTSGs for repair of postsurgical defects of the external
ear.

Methods: We conducted a retrospective review of all FTSGs on the ear performed by 2 surgeons (J. C.,
2000-2014; B. C. L., 2007-2014) after clearance by Mohs micrographic surgery at a single institution.

Results: A total of 1519 FTSGs on the ear were performed between June 2000 and March 2014. The most
common sublocations were the superior helix (38.8%), the crura of the antihelix or scapha (18.9%), and the
back of ear/back of helix (15.4%). The overall complication rate was 1.6%, and the most common
complication was graft failure (1.2%).

Limitations: Data were collected retrospectively from a single institution. Follow-up beyond 3 months
was limited. A standardized assessment tool for aesthetic outcomes was not performed.

Conclusion: By taking advantage of predictable ‘‘pincushioning’’ and combining with local flaps or
cartilage grafts, FTSGs can provide more volumetric replacement than previously described. They reliably
preserve the height and complex topography of the ear with a low complication rate. ( J Am Acad Dermatol
http://dx.doi.org/10.1016/j.jaad.2016.01.028.)

Key words: anatomic location; composite graft; external ear; full-thickness skin graft; Mohs micrographic
surgery; nonmelanoma skin cancer.

A pproximately 8% to 10% of all skin cancers of labyrinthine convexities and concavities together
presenting to Mohs micrographic surgeons pose a unique set of challenges to the Mohs surgeon
occur on the ears.1,2 Studies of head and approaching ear reconstruction. Although arguably
neck basal cell carcinomas have shown that tumors not as aesthetically important as the central aspect of
on the ear tend to present as larger lesions, require the face, the appearance of the ears does significantly
more Mohs layers, and produce larger final surgical influence patient self-perception and well-being.
defects on average than other head and neck sites.3,4 Studies of microtia in the plastic surgery literature
Squamous cell carcinomas on the ear have similarly have shown that abnormalities in ear shape, posi-
been shown to exhibit more aggressive clinical tioning, or symmetry may cause patients significant
behavior, resulting in larger surgical defects.5-7 psychological distress.8,9 For these reasons, appro-
Larger surgical wounds, tightly adherent skin, priate efforts should be extended to the repair of
limited tissue reservoirs, and a complex topography surgical wounds of the ear.

From the Department of Dermatology and Cutaneous Biology, Thomas Jefferson University, 833 Chestnut St, Suite 740,
Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA 19107. E-mail: [email protected].
Philadelphiaa; and Department of Dermatology and Dermato- Published online March 2, 2016.
logic Surgery, Medical University of South Carolina.b 0190-9622/$36.00
Funding sources: None. Ó 2016 by the American Academy of Dermatology, Inc.
Conflicts of interest: None declared. http://dx.doi.org/10.1016/j.jaad.2016.01.028
Accepted for publication January 20, 2016.
Reprint requests: Joshua W. Trufant, MD, Department of Dermatology
and Cutaneous Biology, Sidney Kimmel Medical College at

1
2 Trufant et al J AM ACAD DERMATOL

In addition to aesthetic concerns, the goals of METHODS

reconstruction after tumor removal include func- This study was approved by the Medical
tional preservation or restoration, cost-effectiveness, University of South Carolina Institutional Review
and if possible, a 1-stage repair. There are numerous Board. We performed a retrospective review of all
reconstructive options for surgical defects of the ear, Mohs micrographic surgery defects on the ear
each with advantages and limitations. Secondary- repaired with FTSGs by 2 dermatologic surgeons at
intention healing is a viable choice for small the Department of Dermatology, Medical University
wounds on concave surfaces of South Carolina, after
of the skin, including the tumor clearance by Mohs
external ear.10 Primary CAPSULE SUMMARY micrographic surgery (J. C.,
side-to-side closure is an 2000-2014; B. C. L., 2007-
d Full-thickness skin grafts are a commonly
option for some smaller 2014).
used repair on the external ear.
defects, where the closure All Mohs micrographic
will not introduce anatomic d They are a versatile and reproducible surgery cases and subse-
distortion. However, larger repair option, providing consistent quent repairs during this
wounds on the helix aesthetically pleasing results with low time period were recorded
repaired in this fashion have complication rates. in a commercially available
a tendency to result in a d These repairs can provide significant database (Microsoft Access,
pointed or ‘‘pixie’’ appear- volumetric replacement by taking Mircosoft Corp, Redmond,
ance to the ear. Local random advantage of predictable WA; Malachite Corp, Durham,
pattern flaps may be used to ‘‘pincushioning’’ or combination with NC). The database was
repair smaller wounds, but local flaps or cartilage grafts. searched for any patient who
are problematic for larger underwent FTSG repair of the
defects because of limited ear. Data were collected on
tissue reservoirs and predicated distortions. Wedge sublocation, tumor type, tumor size at presentation,
excision or variations on the Antia-Buch chondro- postoperative defect size, and surgical complications,
cutaneous advancement flap11,12 may significantly which included hematoma, graft failure, and infection.
shorten the ear’s vertical height, diminish the size of All Mohs micrographic surgeries were performed
the lobe, and result in poor aesthetic results. One- with clean technique (nurses and doctors wear
and 2-staged retroauricular flaps such as the mastoid surgical masks and nonsterile gloves), whereas
pull-through flap13 or mastoid interpolation flap14 reconstructions were performed using sterile
are useful for a variety of helical and nonhelical technique (sterilized instruments, sterile gloves,
defects, but may be unnecessarily complex and donor and recipient sites cleaned with a surgical
expensive, and require multiple procedures when scrub). All surgeries were performed in an office
a more simple repair may result in an equally refined setting under local anesthesia. Wounds were
aesthetic outcome. dressed with petroleum jelly, nonstick gauze, and
Full-thickness skin grafts (FTSGs) have been surgical tape, and sutures were generally removed
widely described as a first-line option for reconstruc- 1 week after surgery. Typically, patients received a 5-
tion of cutaneous defects of the upper two thirds of to 7-day course of prophylactic postoperative
the ear.15,16 A recent survey of 20 Mohs surgeons antibiotics.
showed 19% of ear defects were repaired with skin
grafts, among the highest rates of all anatomic RESULTS
locations.17 FTSGs are traditionally selected to repair A total of 1519 FTSGs on the ear were performed
superficial defects, and when properly executed, are over the study period after extirpation of a variety of
a simple, economical, 1-stage repair option that does tumor types, which are summarized in Table I.
not significantly alter the overall dimensions and The most common locations for lesions repaired
topography of the ear. However, in addition to their with a FTSG were the superior helix (38.8%), the
utility for shallow wounds, we have expanded their crura of the antihelix of helical fossa (18.9%), and
role to defects with more significant volumetric the back of helix/back of ear (15.4%) (Fig 1). The
deficiencies than is commonly accepted. This is mean preoperative tumor diameter was 1.23 cm
accomplished by taking advantage of predictable (0.3-4.3 cm). The mean postoperative diameter,
‘‘pincushioning’’ or combination with other flaps or which was equal to the graft diameter, was 2.09 cm
cartilage grafts. Herein we report on our experience (0.7-5.5 cm).
with FTSGs for repair of postsurgical defects of the A total of 24 postoperative complications were
external ear. recorded in 23 patients (1.6%) (Table II). The most
J AM ACAD DERMATOL Trufant et al 3

Table I. Lesion types Table II. Operative measurements and

Lesion type No. %
complications
Basal cell carcinoma 794 52.3 Surgical measurement Mean, cm Range, cm
Squamous cell carcinoma 609 40.1 Preoperative (tumor) diameter 1.23 0.3-4.3
Malignant melanoma 66 4.3 Postoperative (graft) diameter 2.09 0.7-5.5
Atypical melanocytic proliferation 18 1.2
Postoperative complications No. %
Basosquamous carcinoma 18 1.2
Atypical fibroxanthoma 12 0.8 Graft failure (partial or complete) 18 1.2
Other 2 0.1 Hematoma or hemorrhage 5 0.3
Total 1519 100.0 Infection 1 0.1
Total 24 1.6

cell carcinomas being the most common tumor type.

As expected, the most common locations for FTSG
repair included the upper two thirds of the ear, but
our results suggest they can be an appropriate option
for the lower third in select cases as well. We also
found a wide variation in the diameter of defects
repaired with FTSG, ranging from 0.7 to 5.5 cm.
These findings demonstrate that FTSGs are a versa-
tile repair for defects of varying locations and sizes
on the ear.
Perhaps the most striking finding in our review of
postoperative results was the ability of grafts to
provide substantial volumetric replacement and
contour restoration for defects on the upper two
thirds of the ear, including the helical rim (Fig 2). We
have found that, by slightly oversizing the graft and
taking advantage of anticipated pincushioning, a
carefully prepared and apposed FTSG can be used to
aesthetically repair defects of greater breadth and
depth than is commonly described, or where
convention may call for a multistaged flap and/or
cartilage graft. To illustrate this point, Fig 3 compares
Fig 1. Lesion distribution. 2 similar helical rim defects, the first repaired with a
2-staged mastoid interpolation flap and cartilage
common complication was partial or complete graft graft, whereas the second was repaired with only a
failure (1.2% of all procedures, or 75% of all FTSG. As shown, the aesthetic results of the latter are
complications). There were 5 cases (0.3%) of post- excellent, and provide the additional advantages of a
operative hematoma or hemorrhage. Infection was single-stage procedure, including shorter operative
extremely rare (\0.1%). time, reduced clinic visits, decreased expense, and
Donor sites were selected based on color and avoidance of the interim wound care required for
textural matching. Typically, smaller defects (\2 cm) multistaged flaps.
were repaired with ipsilateral postauricular donor Of course, some defects are too large or too
sites, and larger grafts ([2 cm) were harvested from complex to adequately repair with FTSGs alone.
the supraclavicular area. Examples include defects with structural elements
removed or those involving large portions of both
the helical rim and other sublocations. In these
DISCUSSION instances, FTSGs can be combined with flaps
Herein, we present results from over 1500 FTSG (Fig 4) or cartilage grafts (Fig 5) to restore missing
repairs of the ear. A review of the data found that tissue volume and recreate a native anatomic profile.
FTSGs were used to repair defects resulting from a Cartilage grafts are also a useful adjunct when using
variety of tumors encountered on the ear, with basal FTSGs in areas that lack rigid structural support, such
4 Trufant et al J AM ACAD DERMATOL

Fig 2. Typical results of full-thickness skin grafts to repair defects involving the upper two
thirds of the external ear. A, D, and G, Postsurgical defect. B, E, and H, Immediate
postoperative follow-up. C, F, and I, Long-term follow-up.

as the lower third of the pinna. A cartilage graft in this donor and recipient sites are anesthetized using
location prevents distortion of the native contour of lidocaine with epinephrine. If necessary, the surgical
the ear that may otherwise occur as a result of graft defect can be measured or a template cut to size
contraction (Fig 6, A to C ). using gauze or the foil from a pack of suture material.
Our method of harvesting full-thickness grafts is The dimensions of the defect are then drawn onto
as follows: After sterilization with a surgical scrub, the donor site using a surgical marking pen. The
J AM ACAD DERMATOL Trufant et al 5

Fig 3. Comparison of similar helical defects repaired with the combination of a cartilage graft
and 2-staged mastoid flap (A to C) versus repair with full-thickness skin graft alone (D to F).
The end aesthetic outcome is nearly identical with no penalty for the simpler repair.

Fig 4. A, Defect of the front of aspect of the auricle. B, Full-thickness skin graft (superior) and
mastoid pull-through flap (inferior) sutured in place. C, Long-term follow-up.

ipsilateral retroauricular sulcus is our preferred aids in volume replacement and prevents unwanted
donor reservoir, as it provides an excellent thickness, notching. Grafts destined for the front surface of the
color, and texture match for the upper two thirds of pinna are drawn and cut true to size.
the front aspect of the pinna, and leaves an essen- The graft is harvested and thinned to remove all
tially invisible donor scar. For larger defects ([2 cm), subcutis. We leave slightly more dermis in place for
we prefer supraclavicular skin, because repair of a grafts on the helical rim where more volume is
larger secondary defect on retroauricular skin can desired, whereas grafts for nonhelical defects of the
‘‘pin back’’ the ear and cause a visually distracting front aspect of the pinna are thinned to partial- or
reduction in auricular protrusion. Small adjustments split-thickness proportions.18 Particular attention is
to graft size are made based on the location of the paid to the edges of the graft, which are thinned
primary defect. For helical rim defects, we oversize obliquely to ensure excellent apposition with the
our grafts slightly (by approximately 10%) to recipient site. This final step is especially important if
encourage pincushioning or ‘‘trapdooring,’’ which the graft traverses areas denuded of perichondrium
6 Trufant et al J AM ACAD DERMATOL

Fig 5. A and B, Defect on the lower third of the ear repaired with a combination of cartilage
graft and full-thickness skin graft. C, Five-year postoperative follow-up.

Fig 6. Potential complications of full-thickness skin grafts of the ear. A to C, Excessive wound
contraction has distorted the free margin of the helical rim. The addition of a cartilage graft may
have prevented such distortion. D, Hyperpigmentation.

and must therefore rely exclusively on vascular For larger ([4 cm2) nonhelical defects, we typi-
anastomoses at its edges to maintain viability. cally secure the FTSG centrally with a weblike
Fenestration of the recipient cartilage bed may be pattern of basting sutures, thereby eliminating any
performed if the overlying perichondrium is absent. potential spaces for hematoma or seroma formation
However, if the area of exposed cartilage devoid of and encouraging imbibition and inosculation.19 On
perichondrium measures greater than 1 cm2, alter- the helical rim, however, we avoid excessive basting
native reconstructive choices are considered. so as not to inhibit pincushioning and the volumetric
Hemostasis of the wound bed is achieved with replacement it provides. We have found that the rim’s
judicious electrodesiccation. The graft is then convex shape, combined with careful peripheral
anchored in place at 4 cardinal points using absorb- suturing, provides adequate wound bed-graft
able sutures. The remainder is sutured from graft to approximation. We do not use tie-over bolster
recipient skin using running cuticular or simple dressings, as these have been shown to have no
interrupted stitches of absorbable suture. Care is impact on graft survival.20,21 Instead, the graft site is
taken to ‘‘sink’’ the graft into the wound bed by dressed with petroleum jelly and a nonstick pad, and
applying downward, then outward pressure with the bolstered in place with paper tape. Patients are
placement of each stitch, ensuring firm apposition of advised to leave this dressing in place until their
the graft edges and the sides of the wound bed. follow-up visit in clinic, at 1 week. The donor site is
J AM ACAD DERMATOL Trufant et al 7

closed with buried vertical mattress stitches using an 3 or more months later, our length of follow-up
absorbable suture such as poliglecaprone. beyond 3 months is highly variable. We also do not
Barring a contraindication, we typically prescribe use a standardized tool for physician and patient
a course of an antipseudomonal antibiotic such as assessment of aesthetic outcomes. Similarly, there
ciprofloxacin, due to a higher incidence of post- may be discrepancies between the 2 surgeons’
operative infections on the ear as compared to other assessments of graft failure and need for postoper-
anatomic sites.22 Postoperative pain, commonly a ative contouring.
result of perichondritis, is most responsive to nonste- In conclusion, we find FTSGs to be an extremely
roidal anti-inflammatory medications or topical versatile and reproducible single-staged repair
nitroglycerin ointment. The latter has been shown option for surgical defects of the external ear that is
to be effective in the setting of chondrodermatitis well accepted by patients. If sized and sutured
nodularis helicis,23 and we have found it to be a appropriately, FTSGs can provide excellent volu-
useful option for pain management of nonsuppur- metric replacement and contour restoration that
ative perichondritis. Similar to the dosing used for rivals more complicated repairs without altering the
chondrodermatitis nodularis helicis, patients are ear’s overall dimensions or topography.
instructed to apply 2% topical nitroglycerin to the
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