Novel V to Y advancement flap simple technique for reconstructing small defects of ear lobule: Study
The V to Y advancement flap is a useful modality for repairing a variety of skin defects. The flap is designed to transfer skin from an area of relative excess to fill a neighbouring defect. It is a versatile local advancement flap that is technically straightforward and can vary markedly in size.
Surgical technique involves making a "V" shaped incision down to subcutaneous fat, adjacent to the defect. The "V" shaped tissue is then advanced to cover the defect. The resulting donor site is sutured in a straight line which creates a "Y" shaped closure.
Blood supply of the external ear is from the posterior auricular and superficial temporal branches of the external carotid artery. The superior auricular artery bridges these two arteries to form a dependable collateral blood supply. These vessels consistently provide several small perforating vessels that keep the lobule, and consequently the V to Y flap, well vascularized. Additionally, the anterior auricular branch of the superficial temporal artery as well as the occipital artery contribute to arterial supply to the external ear.
The "H-zone" of the face is an area where cutaneous skin cancers are likely to occur. The study carried out by Allen et al aimed to describe the use of the V to Y flap in 6 Caucasian patients with non-melanoma skin cancer of the earlobe.
A review of the literature was performed on the use of the V to Y flap for earlobe reconstruction. Authors then described its use in reconstructing lobular defects in 6 patients. All patients had a non-melanoma skin cancer involving the earlobe. All surgeries were performed under local anesthetic at a tertiary care centre in Halifax, Canada. Defects ranged in size from 1.0 to 1.4 cm. All defects were reconstructed with only a V to Y advancement flap. Patient photographs were taken intra-operatively and post-operatively. For all patients, satisfaction of the final aesthetic result was assessed on a 10 point scale in follow-up at 6 months.
At the centre from 2018 to 2020, this method was well tolerated under local anesthetic in 6 patients with non-melanoma skin cancers of the earlobe. All patients reported an aesthetically satisfying result at 6 months with scores ranging between 8 and 10. Scarring in all cases was minimal. No intraoperative or postoperative complications occurred including infection or bleeding.
The V to Y advancement flap when used for the reconstruction of lobular defects is a relatively simple surgical technique that is well tolerated under local anesthetic in the outpatient setting. Of note, patient selection is important for employment of this approach.
Patients with a tendency for keloid or hypertrophic scarring, congenital external ear malformations such as microtia with limited lobule tissue, or ears that have been previously operated on may not be ideal candidates. This technique is indicated for smaller lesions that involve the lobule and surrounding regions. Its use is limited for larger defects that involve the majority of the lobule and leave little tissue for advancement, or for lesions that are more extensive and involve surrounding cartilage and periauricular structures. Similarly, it is not indicated for aggressive carcinomas or in patients with recurrences that warrant greater tissue margins. However, when indicated, this technique is advantageous from an aesthetic perspective, resulting in fine line scars that compliment the natural creases of the lobule.
All specimens in this study had clear margins on final pathology. However, in the case of a positive margin which requires further resection, this technique could allow for repeated resection without having initially lost a significant amount of transferable tissue which may have been sacrificed using another technique, such as a wedge resection.
Another advantage of this technique is that it minimizes procedural length and recovery for patients in comparison to approaches that involve more complex reconstructions and larger tissue transfers and complicated post operative ear dressings. The donor defect is aesthetically negligible and results in no vertical shortening of the lobule itself, maintaining symmetry with the unoperated ear. Importantly, in author's experience, patients reported high satisfaction rates with their cosmetic results over the 6 month postoperative period. Overall, this is a useful technique that can benefit both surgeon and patient. It is time and cost effective and benefits the patient while avoiding the risk of general anesthetic.
"Use of the V to Y advancement flap for reconstructing defects of the earlobe is a novel yet simple technique that is technically straight-forward, poses minimal risk to the patient, can be performed in an outpatient setting, and in our experience, yields a favourable cosmetic outcome."
Source: Allen et al. Journal of Otolaryngology - Head and Neck Surgery (2021) 50:32