Welcome to this journal review, covering the June twenty twenty-six issue of Dermatologic Surgery. This month we've got two Reconstructive Conundrum pieces, both worth sitting with slowly, since these are the case-based columns where the value is entirely in the flap-selection reasoning rather than in outcomes data. Let's get into them.

The first is a reconstructive conundrum out of the University of Chile, dealing with a combined auricular and scalp defect. The setup: an eighty-one-year-old hypertensive man with an infiltrating basal cell carcinoma of the left upper auricle and adjacent temporal scalp, cleared after three stages of Mohs. What he's left with is genuinely nasty — a full-thickness defect taking out more than half the pinna, involving the helix, helix crus, scaphoid fossa, and part of the antihelix with bare cartilage, plus a separate five-by-three-centimeter retroauricular scalp defect with exposed periosteum.

The authors walk through their differential of options before landing on their answer, and this rule-out process is really the pedagogical heart of the piece. Second intention was off the table because there's no perichondrium on the exposed cartilage and no periosteum on the exposed scalp bone — healing by granulation over bare cartilage would mean debriding it down, which would distort the pinna contour. Direct wedge closure was dismissed too, since that's really only appropriate for helical defects under about a centimeter and a half. They considered an Antia-Buch chondrocutaneous advancement combined with a scalp rotation, but predicted it would produce ear cupping and a visible size mismatch against the contralateral ear. A preauricular transposition or bipedicled interpolation flap alone was rejected because it would leave two-thirds of the reconstructed helix as skin and subcutaneous tissue with no cartilage support in the upper portion — functionally inadequate for eyeglass or hearing-aid support. And a two-stage mastoid interpolation flap was rejected on logistical grounds: harvesting from the mastoid would use up the exact tissue needed to close the primary temporal scalp defect, and in an octogenarian, multistage procedures with additional visits are something to actively avoid if a single-stage option exists.

Their resolution was a triple-flap combination, each doing a distinct job. First, a posterior temporal scalp advancement-rotation flap closed most of the retroauricular defect. Second, a chondrocutaneous helix advancement flap, mobilized from the lobe, brought up skin and cartilage to reconstruct the lower third of the auricular defect — this is the piece providing structural support. Third, a superiorly pedicled preauricular transposition flap, carrying subcutaneous tissue, was folded on itself to create both an anterior lining for the outer pinna surface and a posterior lining for the inner surface plus the anterior temporal scalp gap — essentially building a bilaminar flap out of a single transposition. The preauricular donor site itself was closed with a small cheek advancement. At four months, the patient had healed without complication and had an acceptable aesthetic and functional result, though the authors are honest that without a cartilage graft in that upper folded segment, some of the early postoperative height was lost to flap contraction over time.

The discussion reinforces a few durable principles rather than new data: preserve a minimum of cartilage wherever possible to prevent auricular contracture, the preauricular donor site is excellent for upper helical coverage given its robust vascularity and low donor morbidity, and — the point they explicitly flag as clinically important — age alone should not push you toward staged procedures, since published series show patients over seventy-five do not have higher complication rates than younger patients undergoing equivalent single-stage ear reconstructions. For your practice, the practice-changing takeaway isn't a new flap, it's the combinatorial thinking: when a defect crosses subunits and no single named flap satisfies both structural and coverage needs, stacking flaps that each solve one discrete problem — support, outer coverage, inner lining, scalp closure — in a single session is a reasonable and durable strategy, particularly in elderly patients where you want to minimize the number of trips to the chair.

The second piece is another reconstructive conundrum, this one from Mount Sinai, addressing a multisubunit defect at the junction of the nasal ala, lateral sidewall, and medial infraorbital cheek. The patient is a sixty-one-year-old man, a current smoker, with a recurrent basal cell carcinoma of the left naris, cleared after two stages of Mohs, leaving a three-by-two-point-six-centimeter defect spanning all three of those subunits.

The reasoning here again centers on why simpler options were rejected. A skin graft — composite or split-thickness — was considered but deemed unlikely to survive or look acceptable, both because of the thick sebaceous nasal skin and depth of the defect, and because active smoking meaningfully raises graft failure risk. A staged interpolation flap, either melolabial or paramedian forehead, was also on the table as a way to guarantee robust perfusion over a cartilage graft, but the patient explicitly preferred a single-stage approach, which pushed the authors toward adjacent tissue transfer for better color and texture match plus a reliable single-stage blood supply.

Because the defect approached the alar rim with evidence of external nasal valve compromise, they placed a cartilage graft harvested from the ipsilateral antihelix — a two-and-a-half-centimeter strip with perichondrium — secured into soft tissue pockets flanking the alar defect, to restore both rim support and valve patency. Their stated rule of thumb here is worth remembering: if at least two millimeters of alar rim skin can be preserved, a cartilage graft for structural support is the move; if you can't retain that margin, you're generally better off resecting the whole subunit unless you're doing a fold-over repair.

They then addressed the pieces in a specific order — cheek first, nose second — closing the medial cheek defect with an island pedicle flap along the melolabial fold to create a stable foundation, and only then turning to the nasal component with a nasalis sling flap, a laterally based myocutaneous flap that leverages the nasalis muscle's robust blood supply. Technically, they used bilevel undermining — wide undermining in the subnasalis plane medially, superficial undermining in the prenasalis plane laterally — and deliberately undersized the flap to reduce trapdoor risk and to exploit the purse-string effect as the secondary defect closed, rotating it clockwise and advancing it caudally to recreate the ala.

At one month the patient was pleased with the aesthetic result and had preserved nasal valve competence — the functionally critical endpoint here. There was a wrinkle worth noting for your own practice: the authors chose a narrow caudal flap design specifically to minimize tension, but they candidly acknowledge this smaller surface area likely contributed to hypertrophic scarring at that site, which needed intralesional triamcinolone before settling into an acceptable scar by six months. That's a useful, honestly reported trade-off rather than a clean win.

Their conundrum keys distill to four points, and the sequencing one is the most broadly applicable: when a defect crosses into an adjacent facial subunit, repair that adjacent structure first to create a stable foundation before tackling the nasal component itself. Combined with their emphasis on cartilage grafting whenever alar rim integrity or valve patency is in question, and their reminder that smoking status should actively steer you away from grafts and toward well-vascularized local flaps, this is a solid technical framework rather than a landmark practice-changer — but the sequencing principle and the tension-versus-scarring trade-off on flap sizing are both concrete things you can carry into your next multisubunit alar case.

That wraps our two conundrums for June. Both are excellent illustrations of the same underlying skill — reasoning through why the obvious flap doesn't work before committing to the one that does — and both are worth keeping as reference cases the next time you're staring down a defect that crosses subunit lines. Thanks for listening.