The transposed flaps created by the advancement flap and Z-plasties are supplied by a rich plexus of perforators from both the superficial temporal and posterior auricular arteries, which are branches of the external carotid. Venous drainage is from the accompanying veins (9).

The procedure is designed so that an advancement flap from the posterior limb of the cleft provides the rounded contour of the lower edge of the lobule. Two unequal, unilateral Z-plasties are transposed in a superior direction. An incision on the posterior limb of the cleft bisects this limb, using the lower third as the advancement flap (A-B), and the upper two thirds (B-C-E‘) becomes the lower unilateral Z-plasty. An incision (D-C‘) on the anterior limb of the cleft creates the second unilateral Z-plasty (see Fig. 93.1, D-C‘). The inferior border of the anterior limb of the cleft is deepithelialized to accept the advancement flap (see Fig. 93.1, B‘-A‘).