Once this flap is secured, a re-draping of the skin and removal of excess tissue in front of the ear is accomplished. Before excising skin, we gently pull our skin flaps upward and backward to mark the new location of the inferior portion of the lobule. A slit is then made on the skin so that there will be no downward tension in this area. Avoiding traction on the ear-lobe is essential to prevent a pixie ear, elfin deformity. The hammock effect of the posteriorly placed platysmal flap also assists in preventing this deformity. Once this point is marked, the subcutaneous tissue is inset to the subcutaneous tissue beneath the lobule, ensuring a relaxed closure.
Next the temple tissues are elevated. No skin is removed, but a strong permanent suture to the underlying dermis and temporoparietal fascia of the inferior temporal flap is placed and advanced posteriorly and superiorly, securing it to the temporalis fascia. By avoiding any skin excision, the scar will be thin, with little chance of hair loss. Still, this strong deep suture provides effective elevation of the temple area without a stretched look.
Elevation of the neck is then carried out in the mastoid area using a similar technique of attaching the subcutaneous tissue to the occipital fascia. Having previously undermined the superior flap in this area allows significant advancement. When there is significant laxity in the neck, it may be necessary to trim a small amount of occipital hair bearing skin, but the excision is kept to a minimum, allowing a closure with no tension. The skin is then advanced superiorly in the postauricular area, securing the closure with deep sutures (3-0 or 4-0 Monocryl). This smoothes out any pleating that might occur near the lobule of the ear.
Excess skin in front of the ear is trimmed with minimal tension after excision, and the skin immediately in front of the tragus is defatted, using either the laser or scissors. A subcutaneous closure with 4-0 Monocryl is carried out in this region that results in approximation of the skin edges. We do not want any pull on the skin from the skin sutures.
Skin closure in the hair bearing skin is with staples, but the preauricular area is closed with a simple running 6-0 plain gut suture. Because the subcutaneous closure actually provides the strength of the skin approximation, this very fine skin closure is quite adequate and virtually never leaves stitch marks. The suture usually dissolves in 1 week. The postauricular crease is simply closed with 4-0 Monocryl. Skin sutures are not used here to allow for drainage and evacuation of small hematomas should they occur in the immediate postoperative period. Again, as there is no tension on this closure, the subcutaneous closure is quite adequate.
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