It remains difficult to reconstruct large preauricular defects in a single step with good cosmetic outcomes. We describe here the nasolabial external-rotation (NER) flap, which was combined with a cervical-rotation flap to reconstruct a large skin defect on the preauricular area that included the malar prominence. The patient in case 1 was a 91-year-old man who had a large defect on his right cheek after excision of a squamous cell carcinoma. Three weeks after excision, the 6.5 × 5.5 cm defect was covered with a 5 × 3 cm NER flap, which had a cephalad base and was rotated so its caudal tip covered the malar prominence. The resulting nasolabial defect and the remaining defect occupied the entire buccomandibular area, which was then covered with a 13 × 10 cm cervical-rotation flap. Revision surgery has not been needed for 8.5 months and the cosmetic outcomes are good. The patient in case 2 was a 90-year-old man who had a large defect on his right cheek after excision of a squamous cell carcinoma. Four weeks after excision, the 4.7 × 4 cm defect was covered with an 8 × 3 cm NER flap. The buccomandibular defect was covered with a 9.5 × 5 cm cervical-rotation flap. The flaps survived completely. The NER flap is unique because the flap is moved from the midface to the lateral face. It can reconstruct the malar prominence with thick skin tissue, and it is particularly suitable for older patients. Combining it with a cervical-rotation flap allows for natural subunit reconstruction in a relatively minimally invasive manner with good aesthetic outcomes.
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