The external ear plays a vital role not only in sound collection but also in maintaining facial harmony, symmetry, and aesthetic identity. The lower third of the auricle which includes the ear lobule, inferior helical rim, and adjacent conchal area is particularly important because of its distinct contour, smooth curvature, and prominence in frontal and lateral views. Defects in this region, whether caused by trauma, human or animal bites, burns, congenital deformities, or oncologic excision, can produce highly visible deformities that significantly impact the patient’s appearance and psychosocial well-being. Reconstruction of these structures requires precise restoration of contour, projection, and symmetry with the contralateral ear.

Despite advances in reconstructive surgery, the lower third of the auricle remains one of the most challenging regions to reconstruct. This is primarily due to limited adjacent skin of similar colour, thickness, and texture, as well as the absence of cartilage in the lobule, which eliminates the possibility of structural support. Achieving durable, natural-appearing results is further complicated by the need to conceal scars, avoid distortion of the residual auricular cartilage, and preserve the delicate transition between the lobule, helix, and cheek.

Traditional reconstructive options include composite grafts, postauricular tubed flaps, chondrocutaneous advancement flaps, and regional flaps. While these methods have produced reliable outcomes, many require multi-stage procedures, extended healing periods, or donor-site morbidity. Composite grafts, for example, are size-limited and are associated with unpredictable survival for defects larger than 1.5 cm or those involving avascular beds. Brent’s classical work on autologous cartilage grafting revolutionized total and partial ear reconstruction, yet such techniques are often reserved for larger or more complex defects because they require harvesting rib cartilage and meticulous sculpting, which increases operative time and morbidity (Brent, 1999) [3].

Other methods such as the Antia–Buch chondrocutaneous advancement flap have gained popularity for upper and middle-third auricular defects but are less effective in the lower third, where advancement is restricted by lobular attachments and limited skin laxity. Similarly, postauricular tubed flaps, though robust and well-vascularized, require multiple surgical stages, prolonged immobilization, and may leave visible scarring or partial fixation of the auricle to the mastoid skin (Sinha et al., 2021) [2].

In recent years, there has been renewed interest in single-stage local flaps, which minimize morbidity while providing excellent colour and texture match. Among these, the infra-auricular flap has emerged as a practical and efficient technique for reconstruction of lower-third ear defects. The infra-auricular region contains skin that closely resembles the texture of the lobule and lower helix and has a rich vascular network supplied by branches of the posterior auricular and superficial cervical arteries. These features make it particularly suitable for designing reliable random-pattern flaps with predictable survival.

Hassan (2020) demonstrated that an infra-auricular flap can offer a simple, single-stage, and aesthetically superior solution, especially for lobule and inferior helical defects. His study highlighted favourable advantages including ease of elevation, concealed donor-site scarring, excellent tissue match, and minimal complications [1]. These findings align with the broader reconstructive principles outlined by Park et al. (2012), who emphasized the importance of using local tissue with precise colour and contour match to achieve optimal auricular reconstruction outcomes [4].

Building on this foundation, the present study evaluates the clinical effectiveness of a modified infra-auricular “Trident” flap, a bilobed advancement flap that combines preauricular and postauricular skin to provide adequate length and mobility for defect closure. The flap is designed to be performed under local anaesthesia, requires only a single stage, and preserves the natural outline of the auricle while minimizing donor-site deformity.

Aims and Objectives

·         To evaluate the aesthetic and functional outcome of single-stage infra-auricular (or other local) flap for reconstruction of lower third auricular defects.

·         To assess flap reliability, donor site morbidity, and symmetry compared to the contralateral ear.

• Technique:
1. Under local Tumescent infiltration Anesthesia.
2. Outline flap below the lobule, matching defect width.
3. Elevate in subcutaneous plane, preserving subdermal plexus.
4. Advance/swing into defect; suture in two layers.
5. Donor site closed primarily with undermining on either side.
• Optional cartilage graft (conchal or septal) if lower helix support needed.

Postoperative Care                                                                                                                  

• Light dressing, avoid pressure.
• Suture removal at 7–10 days.
• Follow-up for 3–6 months.

Data Collection and Statistical Analysis

Data were taken directly from the structured Case Data Sheet for all 25 patients Case Data Sheet including: Age, Sex, Defect side, Etiology, Defect size, Flap size, Complications, Aesthetic outcome score, Follow-up period. The analysis was descriptive due to the sample size. Continuous variables were summarized as mean and range, and categorical variables as frequency and percentage. No inferential statistics were performed.

RESULTS (Detailed)

A total of 25 patients underwent lower-third auricular reconstruction using the infra-auricular Trident flap. The following section summarizes demographic characteristics, etiology, defect parameters, flap dimensions, complications, and aesthetic outcomes.

Table No. 1: Demographic Characteristics of Patients (n = 25)

The study included 15 males (60%) and 10 females (40%).
Patient ages ranged from 18 to 71 years, with a mean age of 43.4 years.
Laterality distribution was nearly equal, with 14 left-sided (56%) and 11 right-sided (44%) defects.

Table No. 2: Etiology and Defect Details

Trauma was the most common cause, affecting 16 patients (64%), followed by basal cell carcinoma (20%), squamous cell carcinoma (12%), and congenital cleft lobule (4%). Defect sizes ranged from 1.5 cm to 3.5 cm, with a mean of 2.47 cm.

Table No. 3: Flap Characteristics

All patients underwent reconstruction using a bilobed infra-auricular Trident flap.
Flap sizes ranged from 3.5 cm to 6.5 cm, with a mean of 5.02 cm. There were no intraoperative complications, and all flaps were inset without tension.

Table No. 4: Aesthetic Outcomes and Complications

Flap Survival 24 of 25 flaps (96%) healed without any complications. 1 flap (4%) developed mild venous congestion, which resolved conservatively with warm compresses and topical vasodilators. No cases of flap necrosis, infection, hematoma, or dehiscence were recorded. Donor Site all donor sites healed with minimal scarring concealed under the auricle. No patient reported sensory loss or contour irregularity.

Figure No. 1: The Infra Auricular Flap – Trident Flap By QR Code Video

Reconstruction of lower-third auricular defects remains one of the most technically challenging areas in facial plastic surgery due to the intricate three-dimensional auricular contour, limited availability of adjacent skin with comparable colour and texture, and the aesthetic necessity of maintaining symmetry with the contralateral ear. The lower third comprising the lobule, inferior helix, and adjoining conchal area plays a disproportionately significant role in facial balance. Even minor deformities in this region are noticeable, underscoring the need for refined reconstructive methods that restore both form and function.

Historically, several reconstructive options have been employed depending on the size, depth, and location of the defect. Composite grafts offer simplicity but have limited survival beyond 1.5–2 cm and perform poorly in avascular beds or irradiated tissue. Chondrocutaneous flaps such as the Antia–Buch technique are highly effective for upper and mid-helical rim defects but their advancement is restricted in the lower third due to the absence of cartilage in the lobule and limited skin mobility inferiorly. Brent’s seminal work on auricular reconstruction with autogenous rib cartilage revolutionised techniques for partial and total auricular defects, but such approaches remain invasive, technically demanding, and are not appropriate for isolated lobular or inferior helical defects (Brent, 1999) [3].

Multi-stage regional flaps, such as postauricular tubed flaps, remain reliable options for larger or complex defects. However, these flaps impose significant patient burden due to multiple procedures, prolonged immobilisation, and the potential for bulky or conspicuous donor-site scars. Sinha et al. (2021) highlighted that tubed flaps, while highly vascular, often require secondary thinning and may distort the natural auricular projection or create adhesions to the mastoid skin, affecting ear mobility and contour [2].

In this context, the infra-auricular (Trident) flap emerges as an efficient and aesthetically favourable solution. As originally emphasised by Hassan (2020), the infra-auricular region is an ideal donor site due to its excellent colour, texture, and thickness match to the lobule and inferior helix. Additionally, the region receives a robust vascular supply from the posterior auricular artery and superficial cervical artery, supporting the viability of random-pattern skin flaps even when elevated on relatively narrow pedicles [1]. The flap’s location beneath the ear ensures that donor-site scars remain well concealed in the cervico-auricular shadow, a significant cosmetic advantage.

The present clinical series of 25 patients corroborates these findings. Flap survival was 100%, with only a single case exhibiting mild venous congestion, which resolved spontaneously with conservative measures. This outcome reinforces the predictable vascularity of the flap and validates its design. Furthermore, the aesthetic results were consistently high, with 68% rated as Excellent (score 5) and 32% as Good (score 4). These ratings were based on detailed assessment of contour restoration, colour match, lobular projection, and symmetry with the opposite ear. The absence of poor or fair outcomes demonstrates the flap’s reliability and aesthetic superiority in lower-third reconstruction.

A key advantage of the infra-auricular flap is its single-stage nature, which significantly reduces operative time, patient inconvenience, and healthcare costs when compared with multi-staged alternatives. This advantage aligns with broader reconstructive principles stressed by Park et al. (2012), who noted that local flaps using adjacent tissues with optimal colour and contour match yield the best aesthetic outcomes in partial auricular reconstruction [4]. The bilobed “Trident” modification used in this study provides additional mobility and arc of rotation, allowing tension-free closure even in defects up to 3.5 cm, the upper range observed in our series.

The infra-auricular “Trident” flap represents a reliable, aesthetically superior, and clinically efficient method for reconstructing lower-third auricular defects. Its single-stage design, robust vascularity, and excellent colour–texture match make it particularly well suited for lobular and inferior helical reconstruction, where traditional techniques may fall short. In this study of 25 patients, flap survival was universal, complications were minimal, and aesthetic outcomes were consistently rated as good to excellent, demonstrating the reproducibility and safety of the technique. Donor-site morbidity was negligible, with scars well concealed in the cervico-auricular shadow. Although less effective for large or full-thickness composite defects, the Trident flap offers a practical, low-morbidity solution for small to moderate defects requiring precise contour restoration. Overall, it stands as a valuable addition to the reconstructive options available for lower-third ear defects, providing dependable functional and cosmetic results.

1.       Hassan KM. Infra-Auricular Flap for Single Stage Ear Lobe Reconstruction. Egypt J Plast Reconstr Surg. 2020;43(3):365-371.

2.       Sinha S, et al. Postauricular Tubed Flap in Reconstruction of Auricular Margin Defects. Indian J Plast Surg. 2021;54(2):197-200.

3.       Brent B. Auricular repair with autogenous rib cartilage grafts: total and partial reconstruction. Plast Reconstr Surg. 1999;104:319-334.

4.       Park C, et al. Partial auricular reconstruction. Clin Plast Surg. 2012;39(2):211-230.