Welcome back to the journal review — this is our walkthrough of the March 2026 issue of Dermatologic Surgery. Just one piece on the docket this time, but it's a meaty one, so we're going to spend real time with it. It's a Reconstructive Conundrum case from the Mayo Clinic group — O'Hern, Lohman, and Demer — covering reconstruction of a through-and-through auricular defect with full-thickness loss of the postauricular scalp.

As you know, the Reconstructive Conundrum format isn't an original study — there's no cohort, no control group, no statistics to parse. It's a single, instructive case presented the way we'd actually workshop it at tumor board: here's the defect, here's the differential of reconstructive options, here's what we chose and why, here's how it turned out. So we'll follow that shape rather than forcing it into a methods-and-results scaffold.

The setup: an 80-year-old man with a Brigham and Women's stage T2b recurrent, moderately differentiated squamous cell carcinoma of the left upper posterior ear. After two stages of Mohs, they were left with a genuinely brutal defect — ten by nine and a half centimeters, full-thickness through the ear itself, extending down through the postauricular skin all the way to mastoid periosteum and temporalis muscle. So this isn't just a cartilage-exposed ear defect — it's simultaneous loss of the anterior pinna, the posterior pinna, and the postauricular scalp reservoir that you'd normally reach for first in exactly this situation. And looming over the whole plan was the fact that adjuvant radiation had already been recommended and needed to start promptly, which meant the reconstructive clock was ticking in a way it wouldn't for a typical ear repair.

The authors walk through their differential the way a good conundrum piece should, and this is really the educational heart of the article. First option: the two-staged pedicled postauricular pull-through transposition flap, which is a great workhorse for conchal bowl and antihelix defects — but it depends on having retroauricular tissue to pull from, and here that reservoir was gone. Ruled out on anatomic grounds, not preference. Second option: a temporoparietal fascia flap, paired with skin grafts and cartilage grafting and an advancement flap for the scalp component. This is the versatile go-to for large cartilaginous ear defects, but the authors were explicit about the tradeoffs — real risk of alopecia and facial nerve injury with big flap harvests, and critically, it's typically a two-stage reconstruction. Given that adjuvant radiation was waiting in the wings, a second stage meant delayed healing and delayed radiotherapy, which they weren't willing to accept. Third, they considered secondary intention for parts of the repair and dismissed it for the same reason — too slow, and a graft would need a well-vascularized bed anyway, which wasn't guaranteed here given the depth and radiation timeline.

That left a tunneled flap approach, and the authors are candid about its own tradeoff: you want pedicle bulk and robust blood supply, but you also want a slender enough tunnel that you don't strangle the pedicle and cause venous congestion. Still, for a multisubunit, through-and-through conchal bowl defect like this one, they judged it the best fit — particularly because it's a single-stage solution that doesn't hold up radiation.

What they actually did was a combined repair — a tunneled pull-through single-lobed banner transposition flap for the anterior ear, a rotational advancement flap for the postauricular scalp defect, and a full-thickness skin graft for the posterior auricular surface. The banner flap was raised anteriorly and superiorly off the preauricular cheek, a random-pattern flap running on superficial temporal artery perforators, tunneled under the helical root cartilage above the tragus, then thinned by de-epithelializing the buried segment and inset into the central defect with epidermis facing anteriorly and subcutaneous tissue posteriorly — an elegant way to resurface both sides of the pinna with one vascularized flap. The postauricular scalp defect was closed with broad subgaleal and supraplatysmal undermining, tacked down to periosteum, with a Burow's triangle taken superiorly. And the residual posterior auricular surface got a full-thickness skin graft harvested from the clavicle, fenestrated and quilted onto the flap's subcutaneous pedicle — notably without a bolster, just a pressure dressing for a week, which is worth flagging given the patient was on dual antiplatelet therapy with aspirin and clopidogrel and had notable intraoperative oozing.

Outcome-wise, this is obviously a single case, so there's no statistical inference to translate — just what happened to this one patient, which is exactly the point of the format. Flap and graft were both fully viable at one and three weeks, allowing adjuvant radiotherapy to start on schedule at three weeks postop, which was the whole strategic goal. The flap survived without complication. The one blemish was a trigone deformity at the proximal helix from tension on the rotational advancement closure — revision was offered and declined, patient was satisfied with the cosmetic result at five months. No tumor recurrence at eleven months, and given the high-risk nature of the tumor, they've been following the regional nodal basin with imaging, negative so far.

The discussion frames the tunneled single-lobed banner transposition flap as leveraging the preauricular cheek — a tissue reservoir that's reliably available even when the postauricular one is gone — and usable regardless of whether cartilage is intact. Their practical pearl, which is worth remembering verbatim: before discharging any patient with a tunneled flap, examine it carefully for venous congestion from pedicle constriction, since that's the Achilles' heel of this technique.

So what do you actually take from this into your own practice? This isn't a practice-changing paper in the sense of shifting a treatment algorithm backed by outcomes data — it's one case, n of one, no comparator. But as a technique pearl it's genuinely actionable: when you're faced with a through-and-through auricular defect where the postauricular reservoir is unavailable — whether from tumor extent, prior surgery, or radiation planning constraints — the tunneled preauricular banner transposition flap is a legitimate single-stage alternative to the more morbid temporoparietal fascia flap, particularly when you need to get to adjuvant radiation without delay. The broader take-home is the decision framework itself: match the reconstructive timeline to the oncologic timeline, and don't let a technically elegant two-stage option become the enemy of prompt radiotherapy in a high-risk recurrent squamous cell carcinoma. And practically, remember the trigone deformity risk when you're pulling significant tension for scalp rotational advancement in this region — it's a reasonable trade for speed and vascularity, but worth mentioning to the patient upfront.

That wraps our look at the March 2026 issue. Thanks for listening, and I'll see you next time for the next batch of papers.