The posterior surface of the ear is supplied principally by terminal branches of the auricular artery from the postauricular artery. Care must be taken not to injure this artery in its location along the postauricular groove when dissecting over the mastoid.

The postauricular skin is used as the base to carry the composite skin and cartilage to the new enlarged position of the ear rim. The flap base extends from the anterior scalp to the mastoid.

The anterior skin and cartilage are incised on the remaining ear mass, starting at the onset of the helix anteriorly and curving to the temple (Figs. 88.1 and 88.2). The other inferior incision starts at the helix anteriorly and proceeds across the ear cartilage toward the opposite helical rim, creating a triangular flap anteriorly up to the limit of the temple. It is through the inferior incision that the dissection is carefully taken just to the postauricular skin, and the skin and subcutaneous tissue are dissected off the remaining concha onto the mastoid groove and off the mastoid and temple. To mobilize this flap and give it freedom to move upward and backward, an incision is made transversely in the temple skin.

The skin defect may be so large anteriorly that it is advantageous to elevate a preauricular superiorly based flap to fill in the defect (Fig. 88.3). This has the advantage of wedging the upper limb in place. The defect created by the advancing helix is covered with a full-thickness skin graft or a thick, split, nonperforated skin graft. The graft is placed in the exposed subcutaneous fat of the postauricular skin composite flap. The graft is sutured in and immobilized by a tie-over dressing over
nonadherent gauze. A subcutaneous suture placed from the scalp to the flap and back to the point of origin and tied over a bolster may help support the flap in its new position. The rest of the ear is splinted with saline-moistened gauze and a bulky dressing.