Flaps Practical Reconstructive Surgery

578
III Masterclasses in Reconstructive Flaps
Fig. 52.79 Reconstruction of the anterior lamella with a left-sided para-
median forehead  ap.
Fig. 52.80 A left-sided forehead  ap was chosen, because of a more fa-
vorable position of the pivot point and a more favorable orientation of
the crescent-shaped design, which was made using an exact template of
the defect.
Fig. 52.78 (a,b) The lower eyelid was aggressively released by incising the inferior fornix. The posterior lamella was reconstructed using a buccal
mucosa graft.
a
b
template of the defect (Fig. 52.80). A temporary tarsorrhaphy of
the upper and lower eyelids was perform ed using Frost sutures
for a period of 1 week.
One month later, the forehead ap was re-elevated and ag-
gressively thinned (Fig. 52.81). To add support and restore the
middle lam ella of the lower eyelid, a concha cartilage graft was
sutured between the neoconjunctiva and the thinned forehead
ap (Fig. 52.82). Accidentally, a central vein of the forehead ap
was damaged, causing venous congestion that was successfully
treated with leaching for 5 days (Fig. 52.83).

52 Meeting the Aesthetic Challenges of Complex Facial Reconstructions
579
Fig. 52.81 The forehead  ap was re-elevated and aggressively thinned.
Fig. 52.82 To add support and restore the middle lamella of the lower
eyelid, a concha cartilage graft was sutured between the neoconjunctiva
and the thinned forehead  ap.
Fig. 52.83 Accidentally, a central vein of the forehead  ap was damaged 
causing venous congestion that was successfully treated with leaching.
Fig. 52.84 The pedicle of the forehead  ap was divided and the prox-
imal part was repositioned in an inverted V-manner to reconstruct the
medial brow. The part of the forehead  ap at the medial lower eyelid was 
elevated, thinned, trimmed, and inset.
Five weeks later, the pedicle of the forehead ap was di-
vided and the proximal part was thinned and repositioned in
an inverted V-m anner to reconstruct the m edial brow. The part
of the forehead ap at the medial lower eyelid was elevated,
thinned, trimmed, and inset (Fig. 52.84). Six-and-a-half m onths
later, a m inor scar adhesion of the nasolabial fold was corrected
and the eyelashes of the m edial lower eyelid had to be excised
because of a symptomatic entropion.
Fig. 52.85 shows the patient 8 months after the nal opera-
tion. The position of the lower eyelid was dram atically improved
and the patient did not have any problems with eating and drink-
ing anym ore, because all stulas were closed and he had oste-
ointegrated dental implants.

580
III Masterclasses in Reconstructive Flaps
Fig. 52.85 (a–d) The patient 8 months postoperatively. 
The position of the lower eyelid was dramatically improved
and the patient did not have any problems with eating and
drinking anymore, because all  stulas were closed and he 
had osteointegrated dental implants.
a
b
c
d

Conclusion
Aesthetic facial reconstruction using conventional as well as micro-
surgical techniques is challenging and artistic. Successful aesthetic
facial reconstruction is largely dependent on a proper analysis of
the defect and it requires a clear visualization of the desired end
result and a carefully formulated plan, including possible back-up
options, before the initial surgical intervention. The use of free aps
to reconstruct extensive facial defects often leads to color mis-
match, ap bulkiness, or functional problems such as ectropion,
nasal airway passage problems, or oral incompetence. To optimize
outcomes, a staged approach as part of the initial plan or as part of
touch-ups is usually needed, because a perfect result often needs
more than a single operation. Additional locoregional aps are of-
ten needed and the use of templates can be helpful. Free aps may
be used for lining, obliteration, subcutaneous contouring, or tem-
porary cover that later is replaced by a (pre-expanded) locoregional
ap. For reconstruction of most maxillary or mandibular defects,
free vascularized bone aps with or without fascio- or myocutane-
ous extensions are mandatory. Remember that the patient wants
to look normal. Poor results lead to patient dissatisfaction, not the
number of stages or the complexity of individual procedures.

52 Meeting the Aesthetic Challenges of Complex Facial Reconstructions
581
Menick FJ. Nasal reconstruction with a forehead ap. Clin Plast Surg
2009;36(3):443–459
Menick FJ. Reply: Practical details of nasal reconstruction. Plast Reconstr
Surg 2014;133(1):71e–72e
Menick FJ, Salibian A. Microvascular repair of heminasal, subtotal, and total
nasal defects with a folded radial forearm ap and a full-thickness
forehead ap. Plast Reconstr Surg 2011;127(2):637–651
Moolenburgh SE, McLennan L, Levendag PC, Munte K, Scholtemei-
jer M, Hofer SO, et al. Nasal reconstruction after m alignant tu-
m or resection: an algorithm for treatment. Plast Reconstr Surg
2010;126(1):97–105
Mureau MA, Hofer SO. Maxim izing results in reconstruction of cheek
defects. Clin Plast Surg 2009;36(3):461–476
Mureau MA, Posch NA, Meeuwis CA, Hofer SO. Anterolateral thigh ap re-
construction of large external facial skin defects: a follow-up study
on functional and aesthetic recipient- and donor-site outcome.
Plast Reconstr Surg 2005;115(4):1077–1086
Pribaz JJ, Caterson EJ. Evolution and limitations of conventional au-
tologous reconstruction of the head and neck. J Craniofac Surg
2013;24(1):99–107
Pribaz JJ, Fine N, Orgill DP. Flap prefabrication in the head and neck: a
10-year experience. Plast Reconstr Surg 1999;103(3):808–820
Pribaz JJ, Weiss DD, Mulliken JB, Eriksson E. Prelam inated free ap re-
construction of complex central facial defects. Plast Reconstr Surg
1999;104(2):357–365
van Driel AA, Mureau MA, Goldstein DP, Gilbert RW, Irish JC, Gullane PJ,
et al. Aesthetic and oncologic outcome after m icrosurgical recon-
struction of complex scalp and forehead defects after malignant
tumor resection: an algorithm for treatment. Plast Reconstr Surg
2010;126(2):460–470
Zuidam JM, Coert JH, Hofer SO. Closure of the donor site of the free radial
forearm ap: a comparison of full-thickness graft and split-thickness
skin graft. Ann Plast Surg 2005;55(6):612–616
Figure Credits
1. Sherris DA, Larrabee WF. Principles of Facial Reconstruction. 2nd ed.
New York, NY: Thieme; 2010
Suggested Further Reading
Belm ahi A, Oufkir A, Bron T, Ouezzani S. Reconstruction of cheek skin de-
fects by the ‘Yin-Yang’ rotation of the Mustardé ap and the tempo-
roparietal scalp. J Plast Reconstr Aesthet Surg 2009;62(4):506–509
Cheng MH, Saint-Cyr M, Ali RS, Chang KP, Hao SP, Wei FC. Osteomyocu-
taneous peroneal artery-based com bined ap for reconstruc-
tion of composite and en bloc mandibular defects. Head Neck
2009;31(3):361–370
Cheriex KC, Nijhuis TH, Mureau MA. Osteoradionecrosis of the jaws: a
review of conservative and surgical treatment options. J Reconstr
Microsurg 2013;29(2):69–75
Converse JM, Wood-Smith D. Techniques for repair of defects of the lips
and cheeks. In: Converse JM, ed. Reconstructive Plastic Surgery. 2nd
ed, vol. 3. Philadelphia: WB Saunders; 1977:1575
Ferguson NM, Mathijssen IM, Hofer SO, Mureau MA. Decision making
in reconstruction of defects of the eyelid. J Plast Surg Hand Surg
2011;45(1):45–50
Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstruc-
tive elevator. Plast Reconstr Surg 1994;93 (7):1503–1504
Hofer SO, Mureau MA. Improving outcomes in aesthetic facial reconstruc-
tion. Clin Plast Surg 2009;36(3):345–354
Hofer SO, Mureau MA. Pedicled perforator aps in the head and neck. Clin
Plast Surg 2010;37(4):627–640
Hofer SO, Posch NA, Smit X. The facial artery perforator ap for reconstruc-
tion of perioral defects. Plast Reconstr Surg 2005;115(4):996–1003
Krijgh DD, Mureau MA. Aesthetic and functional outcome following peri-
oral defect reconstruction using the facial artery perforator ap. J
Reconstr Microsurg 2012;28(8):529–538
McDowell F. The classic reprint. Ancient ear-lobe and rhinoplastic opera-
tions in India. Plast Reconstr Surg 1969;43(5):515–522
Menick FJ. A new modi ed method for nasal lining: the Menick technique
for folded lining. J Surg Oncol 2006;94(6):509–514
Menick FJ. Artistry in aesthetic surgery. Aesthetic perception and the sub-
unit principle. Clin Plast Surg 1987;14(4):723–735
Menick FJ. Defects of the nose, lip, and cheek: rebuilding the composite
defect. Plast Reconstr Surg 2007;120(4):887–898
Menick FJ. Facial reconstruction with local and distant tissue: the inter-
face of aesthetic and reconstructive surgery. Plast Reconstr Surg
1998;102(5):1424–1433

Nasal Reconstruction
Lisha McClelland and Nicholas Spencer Jones
53
582

Introduction
Nasal reconstruction has been performed since at least 3000 BC.
From earliest times, the nose was considered not only part of the
facial aesthetic but also a re ection of the individual’s character
and personality. Historically, rhinectomy (cutting o the nose)
was deemed a t punishment for signi cant crimes. Rhinectomy
is rarely meted out today; however, our patients still feel a similar
shame or embarrassment and social isolation. Our role as surgeons
is to help the patient achieve as normal a life as possible, ideally
with a nose that looks good, functions well, and has few long-term
problems. The following chapter is a practical guide to the more
common reconstructive techniques. However, you should be aware
from reading through that the procedures are challenging, they
leave additional surgical scars, the results can be relatively unpre-
dictable, and the outcome will never be as good as patient’s original
nose. Sometimes this means taking a step back and realizing that
a prosthetic nose may be a better option for the patient. If recon-
struction is the best option, then you should carefully balance the
surgical options and have a back-up plan if things do not go well.
Numerous free aps have been described for nasal recon-
struction. We have chosen to describe two—a free pre-auricular
ap and a free radial forearm ap—as they have unique advantages
for reconstruction.

Bilobed Flap (Zitelli’s Flap)
Classif cation

●
Transposition ap
Vascular Pedicle

●
Angular artery branches

●
Facial vein, ophthalmic vein

●
Ophthalmic, maxillary, and facial nerves
Patient Positioning
Supine position with head ring.
Preparing the Graft Site
Step 1: Prepare the Nose
The skin should be prepared with topical antiseptic (e.g., povi-
done-iodine) (Fig. 53.1a).
Step 2: Refresh the Defect
The defect should be made circular and the wound edges refreshed.
Surface Markings
1. Measure the defect.
2. Choose a pivot point 1 radius distance from the defect edge.
This can be medial or lateral (usually lateral) to the defect but
should be in an area of skin excess and sited away from the
medial canthus or alar rim.
3. Using the pivot point as center, mark an arc from the center of
the defect over the donor area.
4. Mark an arc from the defect edge using the pivot point as the
center.
5. The rst lobe of the ap should be placed at 45 to 50 degrees
from the defect, be of equal diam eter to the defect, and be
between the two arc lines.
6. The second lobe should be narrower and extend above the
two arc lines to facilitate closure. It should be placed at 90 to
100 degrees from the defect. To achieve an optim al cosm etic
result, this should lie in a vertical plane. Note that many texts
show an 180-degree arc but this causes a marked dog ear. The
surrounding skin needs wide undermining to allow the ten-
sion on the skin to be distributed (Fig. 53.1b).
Raising the Flap
Step 1: First Incision
The ap should be incised as marked. The triangle of skin be-
tween the defect and the pivot point should be excised to the
same depth as the defect to prevent a dog ear (Fig. 53.1c).
Step 2: Elevating
The rst and second lobes of the ap are incised along the markings
and elevated to the same depth as the defect. This is achieved by
sharp dissection starting where the free edge of the defect abuts the
rst lobe of the ap. Bipolar electrocautery can be used sparingly to
achieve hemostasis on the base but avoid use on the ap (Fig. 53.1d).
Step 3: Mobilizing
The area around the rst and second lobes should be elevated on
a broad front just super cial to the super cial muscular aponeu-
rotic system (SMAS) to facilitate closure.

53 Nasal Reconstruction
583
a
b
f
g
c
e
d
Fig. 53.1 Bilobed  ap. (a) Patient is prepared with topical antiseptic. (b) Surface markings for bilobed  ap. (c) Incising the 
bilobed  ap. (d) Elevating the bilobed  ap. (e) Bilobed  ap placement. (f) Early result from bilobed  ap repair of nasal tip 
defect. (g) Long-term result of bilobed  ap repair of nasal tip defect.1

584
III Masterclasses in Reconstructive Flaps
Patient Positioning
Supine position with head ring.
Preparing the Graft Site
Step 1
The skin should be prepared with topical antiseptic (e.g.,
povidone iodine) (Fig. 53.2a).
Step 2
The edge of the defect and base should be freshened. If the en-
tire subunit is being replaced, any residual part should be excised
now. If part of a subunit is being grafted, then the edges should
be made uniform.
Surface Markings
1. Make a template of the defect. A mirror template from the
contralateral side may be used to aid this process.
2. Mark the natural nasolabial crease on both sides (it may be
helpful to mark this preoperatively by having the patient gri-
mace if it is not obvious).
3. For a lateral nasal wall defect, a superiorly or inferiorly based
ap with a wide proxim al pedicle is used. The template can be
drawn with a “pedicle” and used to assess ap rotation.
4. For a nasoalar defect that is not full thickness and more than
0.5 cm away from the alar rim, an island ap is used. The ap
can taper from the point where the alar crease, upper lip, and
cheek meet and extend the full length of the nasolabial crease
before tapering to a point again (Fig. 53.2b).
5. The ap is drawn to include the template. Rotate the template
180 degrees. Place the template above the nasolabial crease
and trace the template outline onto the skin.
6. If the defect is near the rim, a baton of cartilage harvested
from the conchal bowl or septum needs to be secured across
the defect into the surrounding marginal subcutaneous tissue
in order to minimize notching of the skin (Fig. 53.2e).
Stage 1: Raising the Flap
Step 1: First Incision
The ap is incised as m arked through skin and subcutaneous lay-
ers, stopping before the muscle (Fig. 53.2e).
Step 2: Elevating
Dissection begins distally in the subcutaneous plane super cial to
the facial muscles. Proximally the ap is elevated by very carefully di-
viding the brous strands but preserving the vasculature (Fig. 53.2f).
Step 3: Mobilizing
Elevation of the ap should continue until the ap can be mobi-
lized and rotated 150 degrees without tension on its pedicle.
Step 4: First Lobe Placement
The rst lobe should be rotated into the defect and sutured in situ
with interrupted ne nonabsorbable mono lament (6-0 Prolene
[Ethicon, Somerville, NJ]) sutures.
Step 5: Second Lobe Placement
The second lobe ap is long and narrow. It will need to be
trim m ed at the distal edge to round o the ap before being su-
tured in the defect left by the rst lobe. Wide mobilization of the
surrounding skin will help distribute the tension and achieve a
good closure (Fig. 53.1e).
Step 6: Closure
The defect left by the second lobe ap can now be closed in a lin-
ear fashion with interrupted sutures if the surrounding area has
been adequately mobilized (Fig. 53.1f).
Important Anatomical Structures
Identi ed and raised with the ap:

●
Skin and subcutaneous tissue
Identi ed and preserved:

●
Super cial muscular aponeurotic system (SMAS)

●
Upper and lower lateral cartilage and perichondrium
Clinical Perspectives
The bilobed ap is used for lesions in the lower third of the nose
measuring 0.5 to 1.5 cm (Fig. 53.1g).
Hints and Tips
Ensure m eticulous hemostasis. Underm ine widely to reduce ten-
sion during the closure.

Nasolabial Flap and Island
Nasolabial Flap
Classif cation

●
Transposition ap: two-stage procedure
Vascular Pedicle

●
Myocutaneous perforating vessel from the facial artery
supplies the inferiorly based ap and the angular artery
supplies the superiorly based ap.

●
Venous drainage is to the facial vein.

●
The nerve supply to this ap is via the infraorbital nerve.

53 Nasal Reconstruction
585
a
c
d
b
e
Fig. 53.2 Nasolabial  ap. (a) Patient is prepared with topical antiseptic. (b) Template for island nasolabial  ap. (c) Direct closure of island nasolabial 
ap. (d) Long-term result of island nasolabial  ap. (continued)

586
III Masterclasses in Reconstructive Flaps
Fig. 53.2 (continued) (e) Cartilage graft to alar region.(f) Elevation of a 
superiorly based nasolabial  ap. (g) Nasolabial  ap rotated and sutured 
into place. (h) Donor site closure. (i) Long-term result of nasolabial  ap.2
i
f
e
h
g

53 Nasal Reconstruction
587
Clinical Perspectives
The nasolabial ap may be used to reconstruct the alar subunit or
lower side wall of the nose (Fig. 53.2d). It may be used in conjunc-
tion with an internal lining ap. This ap is not the rst choice for a
full-thickness defect of the alar margin as it is di cult to thin down
the ap su ciently to provide a thin alar rim when it also needs to
be supported by a baton cartilage graft at the margin (Fig. 53.2i). It is
chosen by some patients who wish to avoid the temporary morbid-
ity of a paramedian forehead ap, which will usually provide a su-
perior aesthetic result in the longer term (because it can be thinned
down more and contoured around an alar baton graft and alar rim).
Hints and Tips

●
Ensure meticulous hemostasis.

●
The pedicle must be tension-free.

●
The nasolabial skin edges are not everted to help form the
normal nasolabial crease.

Cheek Advancement Flap
Classif cation

●
Advancement ap
Vascular Pedicle

●
The arterial supply to the medial cheek is from the facial artery.

●
Venous drainage is to the facial vein.

●
The sensory nerve supply is predom inantly via the infra-
orbital nerve, although there may be some cross-over with
zygomatic and m ental branches of the facial nerve. Motor
supply is via branches of the facial nerve.
Patient Positioning
Supine position with head ring (Fig. 53.3a).
Preparing the Graft Site
Step 1: Prepare the Nose
The skin should be prepared with topical antiseptic (e.g., povi-
done-iodine).
Step 2: Refresh the Defect
The ideal defect should be linear with tapering points vertically
at the nasal-facial sulcus.
Surface Markings
Mark the nasal subunits and main facial landmarks (Fig. 53.3b).
1. Mark the infraorbital rim.
2. Mark the nasolabial crease.
3. Mark the alar subunit.
4. Mark the lateral nasal wall subunit.
Step 4
An alar rim cartilage graft is required to support the graft and
reduce notching. This can be harvested from the septum or
conchal bowl. The graft should be approxim ately 2.5 3 0.7 cm. It
will often be atter than the normal alar curvature but contrac-
tion of the skin graft will improve this. A sm all pocket should be
made in the nasal tip just below the lower lateral cartilage rem -
nant and a similar pocket in the lateral alar rim area. The graft
can be sutured to the lower lateral cartilage rem nant with inter-
rupted 4-0 Prolene and the vestibular lining sutured to the graft
with 3-0 Vicryl (Ethicon). The graft m ust be placed as near to
the rim as possible and not in the norm al lower lateral cartilage
position.
Step 5
The ap is trim m ed and positioned over the cartilage graft allow-
ing the skin edge to roll under, forming the nostril m argin. The edge
along the nasal tip and lateral wall are sutured with 6-0 Prolene.
The exposed pedicle can be dressed with antibiotic ointment and
Surgicel (Ethicon). A loose through-and-through Prolene mattress
suture can be used to quilt the layers together (Fig. 53.2g).
Step 6: Closure
The donor site needs to be underm ined laterally by 3.5 cm to al-
low the check to be advanced medially and superiorly. The dog
ear at the inferior nasolabial m argin is excised to align the skin for
closure. Closure is in two layers with 3-0 Vicryl to the subcuticu-
lar layer and 6-0 Prolene interrupted to the skin (Fig. 53.2h). The
island nasolabial ap can be closed directly (Fig. 53.2c).
Stage 2: Dividing the Pedicle
Step 1
The pedicle can be divided at 21 days. The ap is divided at the
cheek level. The donor defect can then be closed.
Step 2
The ap, which remains attached at the nasal tip, can be thinned
and trimmed to t the defect. The edges are rolled inferiorly, con-
tinuous with the nostril margin, to produce an alar base.
Important Anatomical Structures
Identi ed and raised with the ap:

●
Subcutaneous perforators to skin ap m ust be preserved
proximally but not distally as this produces a bulky pedicle.
Identi ed and preserved:

●
The facial m usculature m ust be protected as dam age to
the underlying levator labii m uscle leads to a drooping up-
per lip.

588
III Masterclasses in Reconstructive Flaps
a
b
c
d
e
f
Fig. 53.3 Cheek advancement. (a) Large defect of right cheek, lateral 
nose, and upper lip. (b) Surface marking for nasal subunits. (c) Flap in-
cised along infraorbital rim. (d) Flap incised along nasolabial crease. (e)
Raising the cheek advancement  ap. (f) Wide undermining to the temple 
and preauricular area. (g) Wide undermining to the mandibular region. 
(continued)
g

53 Nasal Reconstruction
589
Fig. 53.3 (continued) (h) Flap advancement without tension. (i) Excess 
skin is excised at infraorbital rim. (j) Excess skin excised at the nasolabial 
crease. (k) Layered closure of cheek advancement  ap. (l) Interrupted su-
tures to skin of cheek advancement  ap.
i
j
k
h
l
Raising the Flap
Step 1: First Incision
The skin should be incised along the infraorbital (Fig. 53.3c) and
nasolabial lines (Fig. 53.3d) following the skin relaxed tension
lines going through the skin and subcutaneous tissue and staying
super cial to the facial muscles.
Step 2: Elevating
The ap should be widely elevated over the SMAS plane
(Fig. 53.3e–g).
Step 3: Mobilizing
The ap is mobilized on a wide lateral base to allow re-draping
without tension. The degree of mobilization required will be de-
termined by the defect. If the ap is being used to repair the later-
al side wall of the nose, greater mobilization is required than if the
ap is only required to reach the nasal-facial sulcus (Fig. 53.3h).
Step 4: Placement
The ap is repositioned to cover the defect. If the ap is re-
pairing a lateral nasal wall defect, deep anchoring sutures can
be placed between the ap and the subcutaneous tissue of

590
III Masterclasses in Reconstructive Flaps
the nasal-facial sulcus. Interrupted 6-0 Prolene sutures are used
and the wound edges of the nasal skin and ap are everted. If any
cheek fat is attached to the ap, then this needs to be removed;
otherwise, it blunts the contour between the nose and the cheek.
Step 5
After advancement and repositioning, there may be excess skin or
dog ears depending on the ap size and degree of mobilization.
It may be possible to excise the excess or use Burow’s triangle
placed at the alar margin and lateral infraorbital region to hide
the scars in natural skin creases (Fig. 53.3i,j).
Step 6: Closure
The ap is sutured in layers with 3-0 Vicryl to the subcutaneous
tissue and 6-0 Prolene interrupted to skin (Fig. 53.3k,l).
Important Anatomical Structures
Identi ed and preserved:

●
Stay super cial to the SMAS in order to avoid damaging the
branches of the facial nerve.
Clinical Perspectives
A cheek advancement ap can be used to repair defects in the lat-
eral wall of the nose; however, with loss of the nasal-facial sulcus,
the cosmetic result is imperfect. Deep sutures between the ap
and soft tissue at the sulcus may improve the overall appearance.
It may, however, be better to advance the cheek as far as the sul-
cus and use a separate ap for the lateral wall of the nose such as
a paramedian ap or, if it is small, a full-thickness skin graft. In
large defects of the lateral wall and medial cheek, a combination
of advancement and rotation of the cheek ap may be necessary.
Hints and Tips

●
Ensure meticulous hemostasis.

●
A large ap may have less tension and give a better cosmet-
ic result than a small ap.

●
Dental rolls can be placed along the nasal-facial sulcus and held
in place with Steri-Strips (3M, St. Paul, MN) to provide gentle
pressure and reduce the chance of a hematoma forming.

●
A second stage may be required to contour the ap, which
may have blunted the junction of the lateral or alar seg-
ments of the nose as they meet the cheek.

Glabellar Flap
Classif cation

●
Rotation ap
Vascular Pedicle
The arterial supply is from the contralateral nasal dorsal artery.
Patient Positioning
Supine position with head ring.
Preparing the Graft Site
Step 1: Prepare the Nose
The skin should be prepared with topical antiseptic (e.g.,
povidone-iodine).
Step 2: Refresh the Defect
The defect should be m ade sym m etrical and the whole subunit
excised if m ore than 50% of it is m issing. An exception to this is
the tip subunit where as m uch skin is retained as possible but the
defect is made symmetrical (Fig. 53.4a).
Surface Markings
Mark the nasal subunits (Fig. 53.4b):
1. Mark the dorsal subunit.
2. Mark the lateral side wall subunit.
3. Mark the nasal tip subunit.
4. Mark the alar subunit.
5. The ap is marked with a wide base on the contralateral na-
sal and medial supraorbital skin, tapering to a point in the
midline of the glabella before extending down the ipsilateral
nasofacial sulcus where it follows the alar crease. An additional
Burow’s triangle will be required at the contralateral alar
crease to allow ap rotation (Fig. 53.4c).
Raising the Flap
Step 1: First Incision
The incision should begin at the contralateral m edial canthal
level and follow the ap outline.
Step 2: Elevating
The ap is elevated in the supraperichondrial plane. This is best
achieved by starting at the edge of the defect and identifying any
remnant of the lower and upper lateral cartilages using sharp scis-
sors in a spreading action. There is a plane of loose connective tis-
sue that aids dissection at this level. As the dissection moves over
the nasal bones, the dissection is developed above the periosteum
and also around the subcutaneous plane in the glabellar region.
Step 3: Mobilizing
The glabella ap is now mobilized on the contralateral nasal wall.
A back cut may be required at the contralateral alar level. The ped-
icle must remain broad to ensure vascularity. The residual triangle
of tissue can be excised. The glabella region and forehead require
undermining in order to achieve primary closure. The dissection

53 Nasal Reconstruction
591
a
b
c
d
e
Fig. 53.4 Glabella  ap. (a) Defect of nasal dorsum, lateral wall, and inner 
canthus. (b) Nasal subunits. (c) Marking out a glabella  ap. (d) Glabella 
ap sutured with 5-0 Prolene. (e) Long-term result of glabella  ap.2

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III Masterclasses in Reconstructive Flaps
Preparing the Graft Site
Step 1: Prepare the Nose
The skin should be prepared with topical antiseptic (e.g.,
povidone-iodine).
Step 2: Refresh the Defect
The defect should be m ade sym m etrical and wound edges
refreshed (Fig. 53.5a).
Surface Markings
1. Mark the nasal dorsum.
2. Mark Burow’s triangles above the brow line (Fig. 53.5b).
Raising the Flap
Step 1: First Incision
The nasal dorsum is incised through skin and subcutaneous tis-
sue on both sides and this normally needs to extend above the
level of the brow. Burow’s triangles are excised.
Step 2: Elevating
The ap is elevated directly above the perichondrium of the up-
per lateral cartilages and any SMAS, and this plane is continued
over the periosteum of the nasal bones.
Step 3: Mobilizing
Mobilization of the ap continues in the sam e plane above the
incision line staying medial to prevent damage to the supratroch-
lear and supraorbital vessels.
Step 4: Flap Placement
The distal ap is trimmed to t the defect.
Step 5: Closure
The ap is sutured in situ with 6-0 Prolene interrupted sutures
(Fig. 53.5c).
Important Anatomical Structures
Identi ed and raised with the ap:

●
The dorsal artery
Identi ed and preserved:

●
Upper lateral cartilage and perichondrium and periosteum
of nasal bones
should continue in the subcutaneous plane, in the vertical line be-
tween the brows. The level of the eyebrows should be preserved and
the skin creases in the forehead matched up as much as possible.
Step 4: Placement
The distal ap is now shaped to t the defect on the nasal dorsum
and thinned as the skin over the nasal dorsum is usually thinner
than that of the forehead before being sutured in position with
6-0 Prolene. A template of the defect may aid in accurate shaping.
Step 5: Closure
Once the ap is sutured in place, the glabella region should be
mobilized sym m etrically and the brow position aligned before
closure. Closure is in layers with 3-0 Vicryl to the subcutaneous
tissue and 6-0 Prolene to skin (Fig. 53.4d).
Important Anatomical Structures
Identi ed and raised with the ap:

●
The nasal dorsal artery and branches
Identi ed and preserved:

●
The supratrochlear and supraorbital arteries should be
preserved to keep all future reconstructive options.
Clinical Perspectives
The rotation of the glabella ap is limited, m aking it useful for
the nasal dorsum and proximal tip defect only. The glabellar scar
can be disguised as a furrow where one often occurs when the
patient frowns (Fig. 53.4e).
Hints and Tips

●
Ensure meticulous hemostasis

●
Maintain a wide pedicle base

Dorsal Advancement Flap
(Rintala Flap)
Classif cation

●
Advancement ap
Vascular Pedicle
The dorsal nasal vessels.
Patient Positioning
Supine position with head ring.

53 Nasal Reconstruction
593

Paramedian Forehead Flap
Classif cation

●
Transposition: two- or three-stage procedure
Vascular Pedicle
The arterial supply is from the supratrochlear artery.
Clinical Perspectives
The skin of the glabella region may be quite thick and sebaceous.
The dorsal advancem ent ap transfers this skin onto the dor-
sum of the nose, which may not give the best cosmetic result
(Fig. 53.5d).
Hints and Tips
Ensure meticulous hemostasis.
a
c
Fig. 53.5 Dorsal advancement  ap. (a) Defect of nasal tip and alar re-
gion. (b) Marking for dorsal advancement  ap. (c) Closure of dorsal ad-
vancement  ap. (d) Long-term result of dorsal advancement  ap.1
d
b

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III Masterclasses in Reconstructive Flaps
allow accurate placement of the ap and ensure an adequate
pedicle length (Fig. 53.6d,e).
2. The pedicle base should be around 1 to 1.5 cm diam eter with
the artery located centrally (if it has been located by ultra-
sound; otherwise the pedicle should be broader).
3. The ap m ay need to extend into the hairline to achieve ade-
quate length, although if the ap is taken diagonally m edially
across the forehead, enough length may be achieved to avoid
entering the hair line (Fig. 53.6f).
4. Once the ap has been marked, recheck that the template
reaches the defect without tension. If not, then re-plan the ap.
Stage 1: Raising the Flap
Step 1: First Incision
The incision should begin above the brow line, although this m ay
have to be extended inferiorly later if additional mobility is re-
quired. The incision should be through the derm is and subderm is
but leave the periosteum intact. The ap remains attached by its
base at the supraorbital rim (Fig. 53.6g).
Step 2: Elevating
The ap is elevated super cial to the periosteum. The forehead is
very vascular and bleeding can be reduced by local pressure on
the forehead to either side of the ap. Diathermy can be used on
the skin edges of the donor site but care should be taken if using
it on the ap. The dissection continues in this plane above the su-
praorbital rim. It is important not to damage the supratrochlear
vessel (Fig. 53.6h).
Patient Positioning
Supine position with head ring.
Preparing the Graft Site
Step 1: Prepare the Nose
The skin should be prepared with topical antiseptic (e.g.,
povidone-iodine).
Step 2: Refresh the Defect
The edges of the defect should be refreshed and further excision
carried out if required to conform to the subunit replacem ent
principal. With the lateral nasal wall, dorsum, and alar regions,
this m eans any residual tissue in the subunit is sacri ced. With
the nasal tip, the 50% rule does not necessarily need to be fol-
lowed as long as the defect is made symmetrical (Fig. 53.6a).
Surface Markings
The supratrochlear artery can be located using a handheld Dop-
pler probe and the course of the artery marked in black per-
manent m arker on the forehead. This enables the pedicle to be
narrowed, which makes mobilization of the ap and primary
closure easier (Fig. 53.6b,c).
1. A template is made of the defect and the pedicle. This can be
held to simulate the position of the ap at the supratrochle-
ar artery and rotated from the nasal defect to the forehead to
a
b
Fig. 53.6 Paramedian  ap. (a) Large defect of nose, upper lip, and right check. (b) Marking out. (continued)

53 Nasal Reconstruction
595
h
i
Fig. 53.6 (continued) (c) Handheld Doppler to identify vessels. (d) Template of 
the defect, including pedicle and rolled edge of alar rim. (e) Template position 
on the forehead and marked out in permanent marker. (f) Template marked 
out extending into hair line. (g) Paramedian  ap incised to periosteum. 
(h) Flap raised to the supraorbital rim. (i) Flap mobilized until it reaches the 
defect without tension. (continued)
c
d
f
e
g

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III Masterclasses in Reconstructive Flaps
Fig. 53.6 (continued) (j) Distal  ap thinning. (k) Paramedian  ap is su-
tured into the defect rolling over the cartilage baton to form the alar rim. 
(l) A small piece of Fibrilar packed around the proximal  ap. (m) Primary 
closure of forehead. (n) Undermining and releasing the forehead.1
j
k
l
m
n
Step 3: Mobilizing
The ap at this stage is m obilized until it reaches the defect with-
out tension. If the ap needs to reach the alar or columella regions
further mobilization is required. This can be achieved by extend-
ing the m edial skin incisions below the plane of the eyebrow me-
dially and sometimes laterally into the eyebrow (Fig. 53.6i).
Step 4: Thinning the Flap
The forehead derm is and subderm is are m uch thicker than the
nasal tissues and the ap needs careful thinning. It is usually safe
to thin the distal subdermis up to 2 cm from the graft edge as long
as the subdermal vessels bleed. This is best achieved by holding
the graft in a dry swab with your nger underneath and using
very sharp curved scissor to cut away excess tissue. Keep a close
eye on the ap vascularity and stop if the tissue either becomes
very pale or fails to bleed. Som etim es if the subcutaneous tissue
is more brous, then pinching it with toothed forceps and cutting
it o the skin with a scalpel will help to thin it down (Fig. 53.6j).
Step 5: Flap Placement
A paramedian forehead ap can be placed on its own to replace a
single-layer defect. The ap is sutured along the distal portion with
6-0 Prolene (Fig. 53.6k). The edges of the pedicle are left exposed

53 Nasal Reconstruction
597
Step 6: Closure
The donor site defect can norm ally be closed (Fig. 53.6m). The
forehead needs to be widely undermined across its entire breadth
in a plane above the periosteum. Once a plane has been m ade, the
dissection can often be developed using blunt dissection with a
nger cutting any brous bands exposed (Fig. 53.6n). The fore-
head skin has a tight capsule of brous tissue (the galea) in the
subdermis that resists mobilization. This needs incising with a
at this stage and bipolar diathermy is used to stop oozing of the
skin edges. This can be dressed with Surgicel or Fibrilar (Ethicon)
and antibiotic ointment. It can ooze for 2 days (Fig. 53.6l).
A paramedian forehead ap may also be used as part of a
full-thickness reconstruction with a septal lining ap and car-
tilage graft for support. In the alar region, the ap needs to be
rolled over the cartilage baton graft to m ake a new nostril edge.
The conchal cartilage m ay be excised via a postauricular incision
without a ecting the external shape of the ear (Fig. 53.7).
a
b
Fig. 53.7 Conchal cartilage graft. (a) Inject local anesthetic into the post-auricular region. (b) Incise post-auricular skin. (c) Post-auricular conchal 
cartilage exposed. (d) Conchal cartilage excised. (e) Postauricular incision closed. (f) Para n gauze dressing to conchal bowl. (continued)
c
d
e
f

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III Masterclasses in Reconstructive Flaps
defect site. The ap can then be thinned and shaped to precisely
t into the defect. The ap may need further thinning at this stage
before being sutured in position with 6-0 Prolene (Fig. 53.8a–d).
Step 2: Closure
To achieve a good cosmetic result, it is important to restore the
brow line when closing the donor site. The brow line should be
marked to match the contralateral side. The lower part of the
original incision may need to be partially excised and excess
tissue rem oved to allow the pedicle base to be reinserted and
restore the brow line. As the pedicle has drawn a lot of tissue
medially, its base around the supratrochlear vessels needs to be
debulked in order to avoid the supraorbital rim being too bulky
(Fig. 53.8e–f).
Stage 3
Step 1: Restoring the Alar Crease
If the paramedian ap is used to reconstruct the lateral wall
and alar region, then a new alar crease must be created. This is
usually done 4 weeks after the second stage. The new crease is
marked using the contralateral crease as a guide. The skin and
subcutaneous tissue are incised along this line using a scalpel.
scalpel in a vertical plane using m ultiple super cial incisions
under the subdermis. The mobilized skin is then repositioned to
close the defect by matching the forehead creases. Deep mattress
tension sutures are required in the subderm al layer using 2-0
Vicryl. After the forehead is repositioned, there is an excess of
skin superiorly especially if the incision extends into the hairline.
This can be addressed by extending one side of the incision, often
into the hairline and excising the excess triangle of skin. The skin
is sutured with 5-0 Prolene. If the donor site cannot be closed
primarily, it should be left to heal by secondary intention rather
than using a free graft. If it is kept clean and moist, it may granu-
late for 2 to 4 weeks and rem ain red for several m onths, but if left,
it fades and rarely leaves a bad scar. Healing by secondary inten-
tion gives a better result than using a split-thickness skin graft.
Stage 2
Step 1: First Incision
After 4 weeks, the pedicle can be divided. If vascularity is question-
able, a tourniquet can be applied to the pedicle to check whether
there has been enough angiogenesis for the donor tissue to be
viable; if the donor tissue remains viable, the procedure continues.
If there is any doubt, it should be delayed for another week before
repeating the process. The incision should be made just above the
g
h
Fig. 53.7 (continued) (g) Conchal cartilage for baton graft. (h) Baton of cartilage cut to length. (i) Pocket under the alar margin for baton graft. (j) Baton 
inserted and sutured to lower lateral remnant. 
i
j

53 Nasal Reconstruction
599
a
b
c
d
e
f
Fig. 53.8 Paramedian  ap reconstruction stage 2. (a) Four weeks after pri-
mary repair. (b) Division of pedicle. (c) Flap is trimmed and thinned to  t 
defect. (d) Proximal edge is sutured into nasal defect. (e) Pedicle remnant 
is trimmed, thinned, and sutured into forehead defect. (f) Second-stage 
nasal reconstruction.

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III Masterclasses in Reconstructive Flaps

Septal Flap
Classif cation

●
Transposition ap
Vascular Pedicle
The septal branches originate from the facial artery and the inci-
sive artery.
Patient Positioning
Supine position with head ring.
Preparing the Graft Site
Step 1: Prepare the Nose
The skin should be prepared with topical antiseptic (e.g.,
povidone-iodine).
Step 2: Refresh the Defect
The defect wound edges should be refreshed.
The subcutaneous tissue can then be carefully debulked using a
scalpel, sharp scissors, or Henley forceps with a twisting action
(Fig. 53.9).
Important Anatomical Structures
Identi ed and raised with the ap:

●
Try and identify the supratrochlear artery and protect it
during dissection.
Clinical Perspectives
If the ap includes portions of hair-baring skin, this can be ad-
dressed with depilatory creams or laser hair removal at a later
date. Care needs to be taken when thinning down the ap in
heavy smokers and diabetics.
Hints and Tips

●
Ensure meticulous hemostasis.

●
Ensure the ap remains well vascularized when thinning.

●
A tension-free repair is essential to maintain the vascularity
and reduce retraction, which can lead to a poor cosmetic
result.
Fig. 53.9 Paramedian  ap reconstruction stage 3. (a) Prior to stage 3. (b) Alar crease incised and pedicle remnant debulked.
a
b

53 Nasal Reconstruction
601
Step 4: Placement
The ap is sutured in position with 4-0 Vicryl Rapide.
Important Anatomical Structures
Identi ed and raised with the ap:

●
The ap should be raised including the perichondrium.
Identi ed and preserved:

●
Septal cartilage and contralateral mucoperichondrium.
Clinical Perspectives
The septal ap is most commonly used as part of a full-thickness
reconstruction of the alar region.
Hints and Tips
The graft can be covered in antibiotic ointm ent and supported
with Surgicel.

Preauricular Free Flap
Classif cation
The preauricular region is a common donor site for free grafts and
vascularized free aps as it is similar in color and texture, the scars
Step 3: Local Anesthetic
The septum should be injected with lignocaine and adrenaline
(1:80,000) in a subperichondrial plane.
Surface Markings
The end of the cartilaginous septum should be palpated and its
shape discerned (Fig. 53.10a).
Raising the Flap
Step 1: First Incision
The incision begins in the hemitrans xion position at the end of
the cartilaginous septum. The incision curves posteriorly as high
as possible on the septum for 3 cm in the subperichondrial plane.
The incision then turns to the vertical plane for 1 to 1.5 cm be-
fore turning 90 degrees again to come forward to maintain a ap
width of 1 to 1.5 cm superiorly and anteriorly. The incision curves
downward and backward, to allow mobilization of the ap while
maintaining a wide pedicle that includes the perichondrium.
Step 2: Elevating
The ap is elevated w ith a Freer elevator in a sim ilar fashion to a
septoplasty ap.
Step 3: Mobilizing
Once elevated, the ap is m obile on an inferiorly based pedicle
and can rotate to provide internal nasal lining (Fig. 53.10b).
Fig. 53.10 Septal  ap. (a) Surface marking for septal  ap. (b) Right anterior sep-
tal  ap rotated into nasal vestibule.
a
b

602
III Masterclasses in Reconstructive Flaps
Step 2: Elevating
The vascular pedicle is identi ed and preserved. The rem aining
subcutaneous tissue is divided to the SMAS level.
Step 3: Mobilizing
The vascular pedicle is ligated and divided at the frontal branch
of the superficial tem poral artery, fully m obilizing the free
flap.
Step 4: Placement
The ap is draped into position and the pedicle is passed through the
previously made tunnel to the recipient vessels before anastomosis.
Step 5: Closure
The ap is sutured in place with 3-0 Vicryl to the subcutane-
ous layer and interrupted 6-0 Prolene to skin. The donor site
will normally close primarily after wide undermining of the re-
maining skin. The skin is sutured with interrupted 6-0 Prolene
(Fig. 53.11b).
Important Anatomical Structures
Identi ed and raised with the ap:

●
Always identify and protect the vascular pedicle.
Identi ed and preserved:

●
Elevation of the ap should be above the neuromuscular
plane to preserve normal facial movements.
can be easily concealed, and the tissue is thin and pliable. The alar
rim or tragal cartilage can also be harvested as a composite graft.
Vascular Pedicle
The super cial temporal artery branches.

●
Mean artery caliber: 0.65–0.82 mm
Patient Positioning
Supine position with head ring.
Preparing the Graft Site
Step 1: Prepare the Nose and Donor Site
The skin should be prepared with topical antiseptic (e.g.,
povidone-iodine).
Step 2: Refresh the Defect
The defect should be m ade sym m etrical and wound edges
refreshed.
Step 3: Identify the Recipient Vessels
The facial artery and vein are used for m icrovascular anastom osis
if required. The m ost com m on site for the anastomosis is the sub-
mandibular region. However, the pedicle from a free preauricu-
lar graft may be insu cient to span this distance. One solution
to this is to use an intermediary vein graft to bridge the graft;
another option is to nd the facial vessels in the nasolabial fold.
Once the vascular bundle is identi ed, a tunnel is m ade in the
subcutaneous plan to the site of reconstruction through which
the vascular pedicle from the graft can be passed.
Surface Markings
1. Doppler ultrasound can be used to identify the super cial
temporal artery and branches.
2. A template of the defect is made.
3. The template is placed in the preauricular donor region, ori-
entated so that the donor vessels can be easily anastom osed to
the recipient vessels.
4. Ideally the template edge should be in line with the preauric-
ular skin crease.
5. The template is marked onto the skin.
6. Closure of the donor site may require further skin excision.
This should be marked out.
Raising the Flap
Step 1: First Incision
The skin is incised around the template (Fig. 53.11a).
Fig. 53.11 Preauricular  ap. (a) Preauricular skin  ap. (b) Closure of 
donor site.2

53 Nasal Reconstruction
603
Surface Markings
1. Doppler ultrasound can be used to identify the course of the
radial artery.
2. A template of the defect is made. This may be partitioned into
speci c subunits for reconstruction with the lining subunit
being sited proxim ally such as vestibule or nasal oor, and
columella distally.
3. The template is placed along the course of the radial artery as
distally as possible to maximize the length of the pedicle.
4. The template is marked onto the skin.
5. Closure of the donor site may require further skin excision.
This should be marked out.
Raising the Flap
Step 1: First Incision
The skin is incised as around the template.
Step 2: Elevating
The vascular pedicle is identi ed and preserved. The ap is usual-
ly elevated below the fascial layer so the ap consists of skin, sub-
cutaneous tissue, and fascia. Bone may also be included en bloc.
Step 3: Mobilizing
Dissection of the pedicle can continue proximally to the elbow; at
this point, the venae com itantes become a larger-caliber collect-
ing vein. The vascular pedicle is ligated and divided, fully mobi-
lizing the free ap (Fig. 53.12b).
Step 4: Placement
The ap is draped into position and the pedicle passed through
the previously m ade tunnel to allow anastom osis of the pedicle.
If individual subunits are used, they can now be sutured into po-
sition using 3-0 Vicryl. The lining is sutured rst followed by any
external components (Fig. 53.12c).
Step 5: Closure
The donor defect may close primarily; however, if a large paddle
has been rem oved, a split skin graft m ay be required and the arm
imm obilized for 10 days. If the radial forearm ap is being used
purely for lining with a plan for a secondary forehead ap, a split
skin graft can be used for temporary cover.
Important Anatomical Structures
Identi ed and raised with the ap:

●
Always identify the vascular pedicle.
Identi ed and preserved:

●
The function of the neuromuscular units of the forearm
should be protected and preserved.
Clinical Perspectives
The preauricular free ap is ideal for small to medium-sized skin
defects and can be used in conjunction with septal lining aps
for full-thickness defects. The ability to harvest tragal cartilage
as composite makes it suitable for defects around the nostril and
columella.
Hints and Tips
Ensure meticulous hemostasis.

Radial Forearm Free Flap
Classif cation
A free radial forearm ap has a subcutaneous vascular pedicle. It
provides a large vascularized soft tissue paddle for reconstruc-
tion (10 3 20 cm) and can be used alone, as part of a composite
with the radius, or with separate bone, cartilage, and addition-
al aps and grafts for large nasal defects. It can be divided into
two in order to provide an internal lining as well as replacing ex-
ternal skin.
Vascular Pedicle
The artery:

●
Artery caliber: 1.0–2.5 mm

●
Venae comitantes caliber: 0.8–1.2 mm

●
Collector vein caliber: 2–3 mm
Patient Positioning
Supine position with head ring; arm extended on arm board.
Preparing the Graft Site
Step 1: Prepare the Nose and Donor Site
The skin should be prepared with topical antiseptic (e.g.,
povidone-iodine).
Step 2: Refresh the Defect
The wound should be m ade sym metrical and edges should be re-
freshed (Fig. 53.12a).
Step 3: Identify the Recipient Vessels
A small incision is made below the mandible over the facial ves-
sels. The facial artery and vein are identi ed. A tunnel is made
under the cheek from the nose to the incision. The vascular ped-
icle can then be passed through and anastomosed to the facial
vessels.

604
III Masterclasses in Reconstructive Flaps
a
b
c
d
e
Fig. 53.12 Radial free forearm  ap. (a) Large defect of right lateral nose, cheek, and upper lip. (b) Composite free radial forearm  ap with radial bone. 
(c) Radial forearm free  ap in situ leaving later nasal wall defect. (d) Free radial forearm  ap. (e) Radial forearm repair of right cheek with paramedian 
repair of lateral nose. (f). Long-term result from radial forearm repair of right cheek with paramedian repair of lateral nose.
f

53 Nasal Reconstruction
605
Raising the Flap
Step 1: First Incision
An incision is made a millimeter inside the rim of the conchal
bowl through both the skin and cartilage (Fig. 53.13b).
Step 2: Elevating
The dissection begins between the perichondrium and the sub-
cutaneous tissues posteriorly.
Step 3: Mobilizing
The cartilage and skin are dissected out en masse as a free tissue
transfer.
Step 4: Closure
The defect in the conchal bowl is repaired with a “ ip- op” graft
from the postauricular skin. A template of the conchal defect is
made and a disk of postauricular skin just underlying the defect
is marked using the template (Fig. 53.13c), incised (Fig. 53.13d),
and gently mobilized; the skin is inverted and passed through the
defect before being sutured in place with 3-0 Vicryl (Fig. 53.13e).
The post-auricular wound is closed by underm ining and m obi-
lizing the postauricular tissues. A pressure dressing made from
folded para n gauze is sutured into the conchal bowl using 2-0
silk. This is removed 1 week postoperatively.
Step 5: Graft Preparation
The graft needs to be shaped to the defect. It is helpful to use a
template of the defect. If possible, the cartilage graft should over-
lap cartilage remnants in the nose to allow secure xation.
Step 6: Closure
The cartilage layers can be sutured with 4-0 Prolene, burying the
knots on the inside. The skin layers can then be sutured with 6-0
Prolene, everting the edges.
Important Anatomical Structures
Identi ed and raised with the ap:

●
Cartilage and skin are harvested as one.
Identi ed and preserved:

●
The rim of the conchal bowl m ust be preserved to reduce
the risk of long-term cosmetic changes to the auricle.
Clinical Perspectives
A composite graft can be useful in repairing internal defects
around the nostril margin when a septal ap is not available. The
Clinical Perspectives
A microvascular radial free forearm ap allows a moderate volume
of vascularized tissue to be transferred to the nose, which is neces-
sary in cases of signi cant tissue loss where local aps alone are in-
su cient. The color and texture match, however, are not ideal. The
ap is therefore more commonly used as a lining ap and vascular
bed for other external reconstruction techniques (Fig. 53.12d–f).
Hints and Tips

●
Ensure meticulous hemostasis.

●
Plan the reconstruction templates with precision allowing
enough room between the subunits for the pedicle to turn
without compressing the vessels.

Composite Graft
Classif cation
Though the composite graft is a free tissue transfer and not a ap,
a chapter on nasal reconstruction that does not include its uses
would be incomplete (Fig. 53.13a).
Vascular Pedicle
Neovascularization occurs from the surrounding vascularized
mucosa and skin.
Patient Positioning
Supine position with head ring.
Preparing the Graft Site
Step 1: Prepare the Nose
The skin should be prepared with topical antiseptic (e.g.,
povidone-iodine).
Step 2: Refresh the Defect
The defect should be m ade sym m etrical and wound edges
refreshed.
Step 3: Prepare the Ear
The skin should be prepared with topical antiseptic (e.g.,
povidone-iodine) and then injected posteriorly with lignocaine
and adrenaline (1:80,000).
Surface Markings
1. A template is made of the primary defect.
2. The conchal bowl of the ear is marked 1 mm inside the rim.

606
III Masterclasses in Reconstructive Flaps
Fig. 53.13 Composite graft. (a) Soft triangle notching and scar following facial trauma. (b) Left conchal composite graft. (c) Surface marking for  ip-
op  ap. (d) Post-auricular  ip- op graft incised. (e) Post-auricular graft suture in situ. (f) Long-term result of conchal composite graft.
a
b
c
d
e
f

53 Nasal Reconstruction
607
Burget GC, Walton RL. Optimal use of m icovascular free aps, cartilage
grafts, and a paramedian forehead ap for aesthetic reconstruc-
tion of the nose and adjacent facial units. Plast Reconstr Surg
2007;120(5):1171–1207
Ebrahimi A, Nejadsarvari N, Koushki ES. Application of modi ed Rinta-
la ap in nasal tip reconstruction. Am J Otolaryngol 2012;33(6):
685–688
Han Y, Pan Y, Yang L, Ai Y, Ma G, Xia W, Zhang H. Resurfacing partial nose
defects with a retroauricular skin/cartilage free ap. Ann Plast Surg
2011;67(1):34–39
Henry EL, Hart RD, Mark Taylor S, Trites JR, Harris J, O’Connell DA, Seikaly
H. Total nasal reconstruction: use of a radial forearm free ap, ti-
tanium mesh, and a paramedian forehead ap. J Otolaryngol Head
Neck Surg 2010;39(6):697–702
Hidalgo DA. Fibula free ap: a new m ethod of mandible reconstruction.
Plast Reconstr Surg 1989;84(1):71–79
Michlits W, Papp C, Hörmann M, Aharinejad S. Nose reconstruction by
chondrocutaneous preauricular free aps: anatomical basis and
clinical results. Plast Reconstr Surg 2004;113(3):839–844; discus-
sion 845–846
Oh SJ, Jeon MK, Koh SH. Nasolabial facial artery and vein as recipient
vessels for midface microsurgical reconstruction. J Craniofac Surg
2011;22(3):789–791
Ozek C, Gundogan H, Bilkay U, Alper M, Cagdas A. Nasal colum ella recon-
struction with a composite free ap from the root of auricular helix.
Microsurgery 2002;22(2):53–56
Raghavan U, Jones N. Nasal reconstruction. In: Gleeson M, ed. Scott-
Brown’s Otorhinolaryngology Head and Neck Surgery. Boca Raton:
CRC Press; 2008
Sherris DA, Larrabee WF. Principles of Facial Reconstruction: A Subunit
Approach to Cutaneous Repair. 2nd ed. New York: Thieme; 2010
Tsiliboti D, Antonopoulous D, Spyropopoulos K, Naxakis S, Goum as, P.
Total nasal reconstruction using a prelaminated free radial forearm
ap and porus polyethylene implants. J Reconstr Microsurg
2008;24(6):449–452
Valentini V, Terenzi V, Bartoli D, Battisti A, Aboh IV, Egidi S, Cassoni A.
Single-step nasal reconstruction with osteocutaneous forearm ap
after total rhinectomy. J Craniofac Surg 2012;23(5):e474–476
Vuyk HD, Lohuis PJ. Cheek reconstruction. In: Facial Plastic and Recon-
structive Surgery. London: Hodder Arnold; 2006
Figure Credits
1. Weerda H. Reconstructive Facial Plastic Surgery: A Problem -Solving
Manual. 2nd ed. New York, NY: Thieme; 2015
2. Sherris DA, Larrabee WF. Principles of Facial Reconstruction: A Sub-
unit Approach to Cutaneous Repair. 2nd ed. New York, NY: Thieme;
2010
most com m on donor site is the conchal bowl. The cartilage pro-
vides structural support and reduces the degree of scarring and
contraction that can occur with soft tissue repair alone. It can be
used to reconstruct the colum ella, oor of nose, or the alar rim.
It needs to be quilted to the surrounding vascularized tissue. It is
less likely to take in a diabetic or heavy smoker and is unlikely to
survive if the base has had radiotherapy (Fig. 53.13f).
Hints and Tips
Ensure meticulous hemostasis.

Conclusion
As a surgeon you will perform an operation, but your patient
must live with the results. Tim e spent counseling and preparing
your patient preoperatively will ensure you both have realistic
expectations. Discuss what is cosm etically and functionally
achievable and balance this against what the patient feels will be
acceptable. Consider factors that will a ect ap and graft viabil-
ity or wound healing such as diabetes, vascular disease, or pre-
vious radiotherapy. Having the ability to perform a wide range
of techniques allows you to choose the one most suited for your
patient’s needs. Be careful, methodical, and meticulous when you
operate; “measure twice, cut once,” as the 19th century proverb
had it. Despite your best intentions, you will have failures—learn
from those, and always have a back-up plan.
Suggested Further Reading
Burget GC, Menick FJ. The param edian forehead ap. In: Burget GC,
Menick FJ, eds. Aesthetic Nasal Reconstruction. St. Louis, MO:
Mosby, 1994
Burget GC, Menick FJ. The superiorly based nasolabial ap: technical de-
tails. In: Burget GC, Menick FJ, eds. Aesthetic Nasal Reconstruction.
St. Louis, MO: Mosby; 1994:93–115
Burget GC, Menick FJ. Unilateral full-thickness nasal defects. In: Burget GC, Me-
nick FJ, eds. Aesthetic Nasal Reconstruction. St. Louis, MO: Mosby; 1994

608
Facial Allo aps for Face Transplantation
Edward W. Swanson, Devin O’Brien Coon, Ryan J. Murphy, Mehran Arm and, and Chad R. Gordon
54

Classi cation

●
Mathes-Nahai type III

Neurovascular Pedicle
The m axilla and zygom a have periosteal and endosteal blood
supply arising from the internal maxillary and facial arteries.
Communication between the facial and internal maxillary arteri-
al systems allows retrograde perfusion of the maxilla and zygoma
from the facial artery alone, relying on periosteal blood supply.
The facial soft tissue can be divided in thirds, with the lower
two-thirds receiving blood supply from the facial artery and the
upper third receiving blood supply from the super cial tempo-
ral vessels. Facial allo aps including soft tissue of the lower two-
thirds can be based on the facial artery alone. Flaps including
the upper third of the face (6 scalp/ears) are based on the facial
artery and super cial temporal artery, with the external carotid
artery as the source vessel.
Analogous to the arterial supply, venous out ow can be
based on the retromandibular vein for aps including the lower
two-thirds of the face only and the external jugular vein for aps
including the upper third of the face.
Sensation can be successfully restored without form al sensory
neurorrhaphy, as demonstrated by the nation’s rst face trans-
plant. In-grow th of recipient sensory bers allows for complete
restoration of facial allo ap sensation, and is mostly dependent
on the mechanism of injury and underlying anatomy. However,
some authors support preservation of all available sensory nerves
for coaptation (if available), including supraorbital, infraorbital,
buccal, and mental nerve branches, depending on the design of
the facial allo ap.
Motor innervation is provided by the facial nerve. The level
at which the facial nerve is harvested is dependent on the needs
of the recipient and preferences of the surgeon. Neurorrhaphy at
the facial nerve m ain trunk (proxim al to the pes division) has the
advantage of ease of harvest and a single neurorrhaphy for each
side, overall decreasing operative time, preventing intraparotid
dissection, and decreasing overall risk of nerve injury. Other
authors advocate harvesting the facial nerve branches as distal
as possible (in an e ort to prevent synkinesis) and performing
multiple neurorrhaphies as close to the target m uscle as pos-
sible. This technique theoretically limits synkinesia and reduc-
es nerve regrow th length. However, dissecting individual facial
nerve branches is tedious, increases blood loss, risks nerve injury,
multiplies the num ber of neurorrhaphies required, and increases
total operative time.

●
Facial artery mean arterial caliber: 1–2 mm

●
Facial artery length: 7–8 cm

●
External carotid artery mean arterial caliber: 2–3 mm

●
External carotid artery length: 4–5 cm

●
External jugular venous caliber: 4–5 mm

●
Retromandibular venous caliber: 1–2 mm

●
Sensory innervation: trigem inal nerve, cranial nerve (CN)
V including supraorbital, infraorbital, buccal, and m ental
branches

●
Motor innervation: facial nerve, CN VII

Patient Positioning
Supine: head of bed rotated 180 degrees, tracheostomy ventilation.

Surface Markings
Each craniom axillofacial allo ap requires a unique and individual
plan based on the needs of the recipient. Each team needs to de-
cide the goals of transplantation and restoration from both a hard
tissue (skeletal) and soft tissue (muscle/skin) perspective.
The following m arkings can be utilized for patients requiring
reconstruction of the lower two-thirds of the face alone, or those
requiring pan-facial allo aps including the upper two-thirds
with forehead, scalp, and/or ear.
Patients with isolated midfacial and/or mandibular defects:
1. Mark the borders of the ap beginning at the lateral can-
thus, extending laterally to the hairline, following the hairline
inferiorly behind the tragus as done in a face lift, extending
posterior to the angle of the mandible down the lateral neck,
crossing the neck perpendicularly to the contralateral side,
turning superiorly to follow the same incision up to the hairline
and medially to the lateral canthus, proceeding medially along
the inferior fornix of the conjunctiva for patients requiring low-
er eyelid reconstruction (or along a lid–cheek junction line for
those who do not), connecting to the medial canthus and ex-
tending superiorly over the radix, continuing laterally across the
fornix (or lid–cheek junction line) depending on patient needs,
and nally connecting to the original lateral canthus (Fig. 54.1).
2. Mark the external carotid artery.
3. Mark the mandibular notch at the insertion of the masseter
muscle, where facial artery pulsations can be palpated.

54 Facial Allo aps for Face Transplantation
609
allo ap harvest, it is best to err on the side of taking m ore tis-
sue, as the allo ap m ay be edem atous at tim e of closing and is
easily tailored to the recipient upon inset (or at a later date).
The dissection is directed caudally in the subgaleal plane,
which transitions to the subperiosteal plane once the dissec-
tion is 1 to 2 cm cephalad to the supraorbital rim . If sensory
nerve repair is planned, then supraorbital and supratrochlear
nerves are identi ed and releasing osteotom ies are employed
to harvest as m uch length as possible. It is our opinion that sen-
sory nerve repair is not always necessary and m ay be bypassed
in som e instances.
Once at the level of the supraorbital rim s, attention is turned
to the periorbital region. If the recipient has functioning eyelids,
supra- and subtarsal crease incisions are created (at the junction
of the periorbital aesthetic units), excluding the tarsal plates,
levator muscles, and adnexa from the donor allo ap. If the re-
cipient requires eyelid reconstruction, conjunctival incisions are
created along the superior and inferior fornices to include all
periorbital structures. One may also harvest the anterior lamellae
for placement on top of the recipient’s posterior lamellae if viable
pretransplant.
When creating the retroseptal conjunctival incisions, dissec-
tion is carried straight down to the supraorbital and infraorbital
rim s, as in orbital fracture repairs. Once the bicoronal ap is re-
ected and appropriate periorbital incisions are created, atten-
tion is turned to the lateral incisions. (Proceed to Step 4, below.)
Step 3: Superior Incision
(Midfacial Flaps)
In patients requiring midfacial reconstruction alone, the superior
incision is based on recipient needs and again follows the facial
subunit principle. For patients with isolated nasal and oral defects,
incisions can instead follow the lateral nasal sidewalls extending
inferiorly to connect to the nasolabial folds. This approach limits
further native tissue loss in recipients with defects con ned to
the central face. Alternatively, the incision can be extended from
Patients requiring pan-facial allo aps with inclusion of the
upper third of the face:
1. Mark the superior border of the allo ap (ideally pretrichial
for aesthetic purposes), following the hairline and extending
inferiorly as above or including the ear with a postauricular
line as needed, proceeding inferiorly down the neck crossing
contralaterally and extending superiorly along the hairline to
connect to the original starting point.
2. Mark periorbital incisions as needed:
a. For patients requiring upper eyelid reconstruction, follow
the superior fornix of the conjunctiva.
b. For patients with intact functioning upper eyelids, follow a
supratarsal fold (as similar to an upper blepharoplasty) for
optimal aesthetic harmony.
c. For patients requiring lower eyelid reconstruction, follow
the inferior fornix of the conjunctiva as described above.
d. For patients with intact functioning lower eyelids, follow a
lid–cheek junction line for optimal aesthetic harmony.

Raising the Flap
Step 1: Prepare the Donor
Secure the airway with tracheostomy prior to any dissection to
avoid complications when raising the allo ap. Adhere to sterile
technique by preparing the donor w ith povidone iodine solution,
irrigating intraorally, and inserting a throat pack prior to incision.
Provide preoperative antibiotic prophylaxis based on the recom -
mendations of a transplant infectious disease expert (important
to assess both the donor and recipient for past infections).
Step 2: Superior Incision
(Pan-Facial Flaps)
For pan-facial aps, a bicoronal incision is m ade based on the
requirem ents of the recipient. As a general principle for facial
Fig. 54.1 The skin incision lines for raising a facial allo ap for transplantation, 
based on the recipient’s defect. In this instance, a Le Fort II–based maxillofacial, 
double-jaw face transplant is planned.

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III Masterclasses in Reconstructive Flaps
Step 6: Vascular Pedicle Dissection
As aps are created peripheral to central, the external jugu-
lar veins are rst identi ed, labeled, and ligated w ith as m uch
length as possible (Fig. 54.2). The sternocleidom astoid m uscle
needs to be retracted and the carotid sheath is identi ed and
opened. The external carotid artery is dissected free, identi-
fying and ligating the ascending pharyngeal, superior thyroid,
and lingual branches. The facial vein w ill cross over the com -
m on carotid bifurcation. Careful dissection is necessary around
the carotid bulb and if chem oreceptor irritation does becom e
an issue, an injection of plain lidocaine can quickly reverse do-
nor bradycardia. Stylohyoid and digastric m uscles are divided
to expose the facial artery. The external carotid artery is then
m arked w ith a vessel loop inferior to the facial artery. If har-
vesting a m idfacial allo ap, the facial artery can provide ade-
quate perfusion alone into the donor allo ap. For the recipient
vessels, in ow can be obtained from any patent artery and/or
veins on either side, depending on the recipient’s anatomy. Ide-
ally, the surgical team w ill reconstruct two veins for each artery
anastom osed.
ear-to-ear horizontally. In this approach, the incision begins over
the nasofrontal suture and extends bilaterally to the m edial can-
thus, along a subtarsal crease to the lateral canthus, and contin-
ues horizontally to the root of the ear. This incision line provides
the m ost aesthetically sound reconstruction for m idfacial defects,
but potentially requires excision of unharmed native tissue pri-
or to inset if the defect is con ned to the central face. It is also
important to stabilize this area at time of inset with periosteal
sutures and/or Mitek anchors to prevent ap ptosis and lower
eyelid malpositioning.
In either scenario, the dissection is carried down to the naso-
frontal suture and the orbital oors are exposed for future oste-
otomies. As described for periorbital incisions, when harvesting a
pan-facial ap, the periorbital incision is dependent on recipient
lower eyelid function. See Step 2, above, for further discussion. Fol-
lowing creation of the superior incision line and exposure of the
nasofrontal suture and orbital oors, lateral incisions are created.
Step 4: Lateral and Inferior Incisions
In both pan-facial and midfacial designs, lateral incisions extend
from the hairline to the lateral neck along a preauricular/retro-
tragal line analogous to a face lift incision (an exception to this
design would be for central defects where nasolabial incisions
are utilized). The inferior incision extends horizontally across
the inferior neck, connecting the two lateral incisions. Once all
incisions are created, aps are raised from peripheral to central.
Careful attention should be made to lim it the central soft tissue
dissection unless necessary since facial skeletal perfusion bene-
ts from the periosteal attachments.
Depending on the level of facial nerve harvest, dissection
is carried out in a subsuper cial m usculoaponeurotic system
(SMAS) or includes the parotid gland to preserve the facial nerve
trunk. Once medial to the parotid gland, dissection proceeds me-
dially in a subperiosteal plane, preserving all vasculature, facial
muscles, and motor innervation.
Step 5: Facial Nerve Dissection
As previously described, facial nerve repair can be carried out at
the level of the facial nerve trunk or at distal facial nerve branches
depending on available recipient facial nerve and surgeon pref-
erence. In addition, the great auricular nerve should be identi-
ed, dissected, and preserved for potential use as a facial nerve
interposition graft, if needed. For m otor nerve grafting, options
include either portions of the donor’s spinal accessory and/or
phrenic nerves.
When harvesting the facial nerve trunk, dissection proceeds
to the stylomastoid foramen and the parotid gland is included
in the donor allo ap to ensure facial nerve preservation, unless
distal dissection seems most reasonable at the time. The donor
parotid gland can be debulked in future operations at around
1 year, as in the Cleveland experience—especially because, with
time, the gland will atrophy. In contrast, dissection of each indi-
vidual facial nerve branch is accomplished in the sub-SMAS plane
anterior to the parotid gland, obviating the need to include the
parotid gland in the donor allo ap.
Fig. 54.2 The black arrow points to the external jugular vein, which pro-
vides the majority of out ow drainage to the facial allo ap. The red arrow
points to the lower division of the facial nerve.

54 Facial Allo aps for Face Transplantation
611
the defect includes the angles or rami of the mandible, osteotomies
can be made at the level of the ramus. In this scenario, the double
jaw transplant is transferred in maxillomandibular xation (MMF)
prior to ap inset to preserve donor occlusion (Fig. 54.4). Other-
wise, single jaw transplants carry an additional obstacle since hy-
brid occlusion (relationship of donor-to-recipient jaw) is di cult
to optimize and must be addressed preoperatively.
Step 8: Composite
Craniomaxillofacial Allo ap
Disjunction
Following the Le Fort osteotomies (and mandibular sagittal split
osteotomies if indicated), the allo ap remains attached by the na-
sal septum, pterygomaxillary junctions, and vascular pedicles. The
nasal septum is transected using a heavy scissors. Pterygomaxil-
lary disjunction is performed using a curved osteotome. At this
stage, careful attention must be paid to avoid excessive bleeding
from the pterygoid venous plexus and to avoid avulsing the pedi-
cle. Again, cold irrigation, wound packing, and relative hypotension
with the help of anesthesia may be extremely valuable at this time.
Step 7: Osteotomies
A Le Fort–based design can be used depending on the preexist-
ing skeletal defect of the recipient. In burn patients, the under-
lying skeleton m ay be uninjured. However, in those status post
high-energy trauma (i.e., ballistic injury), then often the under-
lying skeleton has been destroyed with critical insult to the sup-
porting buttresses.
Therefore, to reconstruct all facial skeletal defects, the team
should design tailored osteotomies. These will most often follow
a Le Fort pattern (for the upper and midface) and may include the
mandible (i.e., sagittal osteotomies, if from angle-to-angle). Le Fort
osteotomies are created using handheld osteotomes and ne vi-
brating reciprocating saws, especially in areas surrounding the or-
bit. For instance, a Le Fort III style design for midfacial restoration
includes the nasofrontal suture, the orbital oors, the zygomaticof-
rontal sutures, zygomatic arches, and craniofacial disjunction of the
maxilla from the pterygoid plates. One should also employ stan-
dard orthognathic maneuvers to decrease blood loss, such as head-
of-bed elevation, cold saline irrigation, and hypotensive anesthesia;
decreasing donor blood loss helps to ensure that the solid organ
transplant team’s portion to follow is not jeopardized in any way.
Of note, when cutting the orbital oors, it is advisable to har-
vest as much of the oor as possible, as the precise needs of the
recipient may not be readily apparent until insetting the allo ap.
Orbital oor osteotom ies should be m ade using a ne vibrating
reciprocating saw that does not harm soft tissue in order to pre-
serve the globe for later corneal donation (Fig. 54.3).
Analogously to harvesting the orbital oors, the zygomatic
arches should be taken as far posterior as possible in order to pro-
vide ample length for reconstructing the recipient with proper
skeletal projection.
As previously mentioned, some face transplant recipi-
ents may necessitate mandibular reconstruction (6 midfacial
reconstruction). In such cases, sagittal split osteotomies may be
made based on exact patient need. If the defect involves only the
bodies/symphysis of the mandible, bilateral sagittal split osteoto-
mies can be carried out at the level of the angle of the mandible. If
Fig. 54.3 The globe is protected while a  ne reciprocating saw is used to 
perform the infraorbital osteotomies. Preservation of the medial canthal 
ligament may be pertinent depending on whether eyelid reconstruction 
is necessary.
Fig. 54.4 The double jaw allo ap is transferred in maxillomandibular  xa-
tion (MMF) using wire  xation and screws to help preserve donor occlusion.

612
III Masterclasses in Reconstructive Flaps
Step 9: Vascular Pedicle Ligation
Following pterygomaxillary disjunction, the vascular pedicles
are divided bilaterally (ideally, only once the recipient team has
nalized the preparation and rem oval of scar tissue) and the
facial allo ap harvest is complete (Fig. 54.5).
Step 10: Allo ap Perfusion and
Preservation
The facial allo ap is wrapped in sterile saline-soaked gauze and
kept at 4°C. The allo ap may be perfused with a cell membrane
stabilizing solution through an arterial cannula, depending on
the geography of donor procurement in relation to the recipient’s
location.

Clinical Perspectives
Facial allo aps for transplantation should be considered in
patients with:
1. Complicated soft tissue injuries involving multiple key
functional units such as eyelids, nose, and/or lips.
2. Complex hard tissue defects including loss of signi cant
buttress support such as the m axilla, zygom as, palate, orbits,
nasal bones, and/or mandible.

Hints and Tips

●
Less central dissection leads to more predictable hard/soft
tissue perfusion.

●
Preservation of the osteocutaneous ligam ents will de-
crease long-term facial soft tissue ptosis.

●
Key determinants of success include patient selec-
tion and predicted compliance with rehabilitation and
immunosuppression.

●
Facial transplantation is “life giving” rather than “life
saving.” Defects should be nonamenable to standard re-
constructive m ethods, and m ajor com orbidities m ust be
carefully considered.

●
Using adjacent operating room s for synchronization of the
donor and recipient will maximize e ciency and allow
coordination.

●
Cadaver practice sessions tailored to the speci c candidate
awaiting transplantation will greatly improve the surgical
team preparation.
Fig. 54.5 In this instance, a single-jaw midfacial allo ap has been raised with dissection of the vas-
cular pedicles including carotid and jugular veins. Note how the lower face was divided at the labio-
mental fold to help preserve the facial artery cascade and to enhance aesthetic unit relation.

54 Facial Allo aps for Face Transplantation
613
Bojovic B, Dorafshar AH, Brown EN, et al. Total face, double jaw, and
tongue transplant research procurement: An educational model.
Plast Reconstr Surg 2012;130:824–834
Brown EN, Dorafshar AH, Bojovic B, et al. Total face, double jaw, and
tongue transplant simulation: A cadaveric study using comput-
er-assisted techniques. Plast Reconstr Surg 2012;130:815–823
Dorafshar AH, Bojovic B, Christy MR, et al. Total face, double jaw, and
tongue transplantation: An evolutionary concept. Plast Reconstr
Surg 2013;131(2):241–251
Gordon CR, Siem ionow M, Papay F, et al. The world’s experience with fa-
cial transplantation: What have we learned thus far? Ann Plast Surg
2009; 63: 572-578
Gordon CR, Susarla SM, Peacock ZS, et al. Osteocutaneous maxillofacial
allotransplantation: Lessons learned from a novel cadaver study
applying orthognathic principles and practice. Plast Reconstr Surg
2011;128:465e–479e
Gordon CR, Susarla SM, Peacock ZS, Kaban LB, Yaremchuk MJ. Le Fort-
based m axillofacial transplantation: Current state of the art and a
re ned technique using orthognathic applications. J Craniofac Surg
2012;23:81–87
Pomahac B, Lengele B, Ridgway EB, et al. Vascular considerations in composite
midfacial allotransplantation. Plast Reconstr Surg 2010;125:517–522
Pomahac B, Pribaz JJ, Bueno EM, et al. Novel surgical technique for full
face transplantation. Plast Reconstr Surg 2012;130:549–555
Siemionow M, Gharb BB, Rampazzo A. Pathways of sensory recovery after
face transplantation. Plast Reconstr Surg 2011;127:1875–1889
Siemionow M, Papay F, Alam D, et al. Near-total human face trans-
plantation for a severely dis gured patient in the USA. Lancet
2009;374:203–209
Siemionow MZ, Zor F, Gordon CR. Face, upper extrem ity, and concomitant
transplantation: Potential concerns and challenges ahead. Plast
Reconstr Surg 2010;126:308–315

●
The design of the facial allo ap (cutaneous versus osteocu-
taneous, midface versus pan-face) should be dictated by
the recipient defect.

●
All candidates should receive angiography to de ne the
available in ow/out ow vessels prior to transplantation.

●
High-yield screening tests include standard solid organ
methods (e.g., ABO compatibility and cross m atch) in addi-
tion to skin color, facial skeletal size, and other phenotypic
characteristics.

●
Since facial transplantation requires more stringent crite-
ria for candidate m atch (with a m ore lim ited donor pool),
prolonged waiting times frequently occur, which should be
relayed to candidates during informed consent.

●
Inclusion of multiple disciplines on the surgical team will
help improve outcomes via diverse expertise.

●
Per recent experience, the entire ap can be based on the
donor facial artery and facial/external jugular veins. How-
ever, this mandates careful periosteal stripping, especially
centrally. Incorporation of the STAs will allow transplanta-
tion of forehead, upper scalp, and ear elements.
Suggested Further Reading
Alam DS, Papay F, Djohan R, et al. The technical and anatomical aspects of
the world’s rst near-total human face and maxilla transplant. Arch
Facial Plast Surg 2009;11:369–377

614
Facial Artery Perforator Flaps for Perioral
Soft Tissue Defects
Stefan O. P. Hofer and Caroline E. Payne
55

Classi cation

●
Axial, rotation, cutaneous ap

Vascular Pedicle

●
Single facial artery perforator (FAP) and venous plexus

●
Average of 5.7 FAPs are present from the m andible to nasal
alar rim

●
Caliber: ranges from 0.6 to 1.8 mm (average 1.2 mm)

●
Length of perforator from facial artery to skin: range 13 to
51 mm (average 25.2 mm)

Surface Markings

●
Doppler the exact location of the facial artery as a guide to
where the perforators will be.

●
Plan the ap in the jowl line where there is excess skin.

●
Adhere to the aesthetic unit principle for facial reconstruc-
tion when planning the ap.

●
Maxim um ap size: 2.5 3 5 cm with direct closure of
donor site.

Patient Positioning
The patient is in a supine position with the head on a head ring.
The bed is rotated 180 degrees away from the anesthetic equip-
ment for easier access to the head. A nasotracheal tube is a pref-
erence to allow full access to the soft tissues around the nose
and mouth.

Raising the Flap
The FAP ap is m arked as shown after Doppler location of the
facial artery once the perioral defect is present. The chosen per-
forator should be on the edge of the ap to facilitate rotation into
the defect.
Step 1
First, a template for the reconstruction is designed and m arked onto
the adjacent jowl skin in a position so that the perforator-based
ap can reach the zone of reconstruction (Fig. 55.1). Check for
perforators from underneath the wound edge or make an explor-
atory incision through skin in a position that will be incorporated
Fig. 55.1 Skin has already been cut according to template marked.

55 Facial Artery Perforator Flaps for Perioral Soft Tissue Defects
615
Fig. 55.2 The facial artery perforator can be seen running over the white
background.
Fig. 55.3 The pedicle holds the perforator with a small cu  of surround-
ing fat tissue to aid with venous drainage.
into the ap design. The dissection is continued carefully through
the subcutaneous tissues to identify a facial artery perforator as a
pedicle for the FAP ap (Fig. 55.2).
Step 2
After identi cation of the perforator, check the outline of the de-
signed perforator ap and adjust it to allow for optimal rotation
transposition. Continue with the skin incision around the ap
through skin and subcutaneous tissue so that it is completely
raised on one visible facial artery perforator. To protect the del-
icate perforator, leave a sm all cu of surrounding fatty tissue
around the vessels (Fig. 55.3), which will be responsible for pro-
tecting the venous plexus around the perforator in case no clearly
identi able vein runs with the artery.
Step 3
The m eticulous dissection is continued so that the skin island
and soft tissue are free for rotation around the isolated single
facial artery perforator. The ap is inset into the defect and the
donor site directly closed (Figs. 55.4 and 55.5).

Clinical Perspectives
Perioral defects can be reconstructed with adherence to the
aesthetic unit principles (Figs. 55.5 and 55.6).

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Skin and subcutaneous tissue

●
Single facial artery perforator

●
Facial artery
Identi ed and preserved:

●
Facial nerves

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III Masterclasses in Reconstructive Flaps
Fig. 55.4 FAP  ap rotation and inset into the defect.
Fig. 55.5 Final inset of FAP  ap with completely closed donor site.
Fig. 55.6 Perioral defect prior to reconstruction.

55 Facial Artery Perforator Flaps for Perioral Soft Tissue Defects
617

Flap Variations
The FAP ap can be also be used for lower eyelid defects; however,
that design w ill not be optim al for facial reconstruction according
to the aesthetic unit principle.

Hints and Tips

●
Make sure to Doppler the course of the facial artery.

●
Identify the best perforator through checking via the
wound edge or making a strategically positioned explor-
atory incision.

●
The FAP ap will often be slightly congested over the rst
24 to 48 hours.
Suggested Further Reading
Hofer SOP, Posch NA, Smit X. The facial artery perforator ap for recon-
struction of perioral defects. Plast Reconstr Surg 2005;115(4):
996–1003

618
Facial Artery Musculomucosal Flaps
Brian M. Parrett and Julian J. Pribaz
56

Classi cation

●
Axial, musculomucosal ap

Vascular Pedicle

●
Facial artery and its venous plexus; caliber 0.7–0.8 m m ;
length up to 9 cm

Patient Positioning
The patient should be placed in the supine position w ith the
head of the bed rotated 90 to 180 degrees away from the an-
esthesia team . A nasotracheal breathing tube is preferred to
allow full access intraorally. Alternatively, an oral endotracheal
tube can be placed and secured to the contralateral side of the
m outh.

Surface Markings
The course of the facial artery is outlined with a Doppler. The facial
artery musculomucosal (FAMM) ap is centered over the facial artery
and its orientation is oblique, extending from the retromolar trigone
to the level of the ipsilateral gingival labial sulcus at the level of the
alar margin (Fig. 56.1). The width of the ap averages 1.5 to 2 cm, the
length can be up to 9 cm, and the ap is anterior to Stenson’s duct.

Raising the Flap
The FAMM ap is m arked as above and is designed as either a
superiorly based (retrograde ow) or inferiorly based (antegrade
ow) ap (Fig. 56.2).
Step 1
The dissection com m ences at the distal end of the ap with an
incision through the mucosa, submucosa, and buccinator muscle
Fig. 56.1 (a) Intraoral markings for a superiorly based FAMM ap. (b) The facial artery anatomy important to the FAMM ap design (artery in red, facial
muscles in yellow).
a
b

56 Facial Artery Musculomucosal Flaps
619
Fig. 56.2 (a) Superiorly based FAMM ap rotated and transposed for defects of the hard palate, alveolus, maxillary antrum, nose, and upper lip.
(b) Inferiorly based FAMM ap to reconstruct defects of the hard and soft palate, tonsillar fossa, alveolus, oor of mouth, and lower lip.
Fig. 56.4 An inferiorly based FAMM ap inset. A second-stage division
will be required.
b
a
to expose the facial artery. The facial artery is then identi ed in
the buccal fat, divided, and ligated.
Step 2
The remainder of the ap is incised along its lateral borders and
the dissection proceeds just deep to the facial vessels from the
ap tip toward the ap base. The ap is developed containing m u-
cosa, submucosa, a strip of the underlying buccinator, and, most
importantly, the facial artery, which has fairly loose connections
to the buccinator. Because of the m ultiple layers included, the
ap is about 8 to 10 mm in thickness (Fig. 56.3).
Step 3
The ap is then rotated or transposed into the defect location
(Fig. 56.4). The arc of rotation for an inferiorly based ap has
its pivot point inferiorly at the retrom olar trigone. A superiorly
based ap pivots superiorly at the gingival labial sulcus. For pal-
atal defects, a superiorly based ap is generally used if there is
a gap in the alveolar ridge. In patients with intact dentition, an
inferiorly based ap has been used with the ap com ing in from
Fig. 56.3 Fully elevated superiorly based FAMM ap.

620
III Masterclasses in Reconstructive Flaps
behind the maxillary tuberosity. This approach requires a tempo-
rary bite block for approxim ately 10 days and then division and
inset of the ap in a second stage (Fig. 56.5).
Step 4
The donor site is closed in two layers, approxim ating the bucci-
nator muscle and the mucosa. Take care to avoid the opening of
Stenson’s duct.

Important Anatomical
Structures
Identi ed and raised in ap:

●
Mucosa and submucosa

●
Portion of buccinator muscle overlying facial artery

●
Facial artery
Identi ed and preserved:

●
Stenson’s duct

●
Super cial facial muscles

Clinical Perspectives
The FAMM ap is a versatile solution for a wide range of intra-
oral reconstructive needs. When based superiorly, the FAMM ap
can be used to close m ucosal defects in the anterior hard palate,
alveolus, m axillary antrum , nasal oor, septum, and upper lip
(sulcus and vermillion). When based inferiorly, the ap can be
used to close defects in the posterior hard palate, soft palate,
tonsillar fossa, alveolus, oor of m outh, cheek, and lower lip. It is
especially useful for closure of wide palatal clefts where it can be
based inferiorly or superiorly.

Flap Variations

●
Superiorly based ap

●
Inferiorly based ap

Hints and Tips

●
Assure that the ap rem ains axial during dissection with
the facial artery running along the entire length.

●
Assure that there are no twists or constraints in the pedicle
prior to and after ap inset.

●
For palatal stulas, use palatal mucoperichondrial and/or
local turndown aps for nasal lining.
Suggested Further Reading
Pribaz JJ, Meara JG, Wright S, Sm ith JD, Stephens W, Breuing KH. Lip and
verm ilion reconstruction with the facial artery m usculomucosal
ap. Plast Reconstr Surg 2000;105(3):864–872
Pribaz JJ, Stephens W, Crespo L, Gi ord G. A new intraoral ap: facial
artery musculomucosal (FAMM) ap. Plast Reconstr Surg 1992;
90(3):421–429
Fig. 56.5 (a) Palatal defect after excision of a recurrent histiocytoma. (b) Result after reconstruction with an inferiorly based FAMM ap and muco-
perichondrial palatal aps for nasal lining.
a
b

621
located approximately one ngerbreadth below the midpoint of
the lateral border of the scapula and m ay be identi ed by pal-
pation as a depressed area. However, previous texts utilize the
equation D1 5 (D 2 1) / 2, where D is the distance from the m id-
point of the scapular spine to the scapular tip and the triangular
space is located at a distance D1 from the midpoint of the scapular
spine. A Doppler pencil can be used to trace the course of the
artery as it runs parallel along the scapula’s lateral edge to the tip
and beyond. Mapping out the vessel delineates the central axis
of the ap.
An elliptical ap is drawn along the axis of the pedicle with
the superior point of the ellipse being at or near the triangular
space with the m ajority of the ap being below the pedicle. The
ap width can be extended to 12–15 cm without encountering
di culty with primary closure. The total ap length can reach
25–30 cm from the triangular space.

Raising the Flap
(as a Free Flap)
Step 1: Lateral Incision
The dissection begins along the superolateral aspect of the ellipse
and is carried down to the aponeurosis of the infraspinatus and
teres minor muscles. The posterior aspect of the deltoid may be
retracted superiorly for better exposure. The teres minor m uscle
makes up the superior border of the triangular space.

Classif cation

●
Cormack and Lamberty type B

Vascular Pedicle
The circum ex scapular artery is the rst main branch of the sub-
scapular artery and is located approximately 3 to 4 cm from the
origin of the subscapular artery o of the axillary artery. The cir-
cum ex artery bifurcates into an infrascapular and a descending
branch. The infrascapular branch runs horizontal toward the sub-
scapularis muscle while the descending branch surfaces on the
lateral border of the scapula through the triangular space. The omo-
tricipital space, or triangular space, is bordered superiorly by the
teres minor, laterally by the long head of the triceps brachii, and in-
feriorly by the teres major. As it emerges from the triangular space,
the descending branch gives o the scapular cutaneous artery and
then terminates as the parascapular cutaneous artery. The scapu-
lar cutaneous artery runs horizontal and posterior to the scapula
while the terminal parascapular cutaneous artery continues to run
parallel along and beyond the lateral border of the scapula.

●
Mean arterial caliber: ranges from 1.5 to 4.5 m m depend-
ing on the level of transection

●
Mean venous caliber: ranges from 2 to 5 mm

●
Pedicle length: 4 to 14 cm; pedicle can be lengthened with
dissection to the axillary artery

●
Sensory innervation: no distinct sensory innervation of
this area

Patient Positioning
Lateral decubitus positioning is ideal as it gives excellent expo-
sure to the axilla as well as the parascapular area. Access to the
axilla allows for anterior dissection to harvest an extended length
pedicle if needed for a free ap. The arm should be abducted at
90 degrees and prepped into the eld.
The lateral decubitus position also allows for better expo-
sure for ap transfer to the head and neck as well as the axilla and
ipsilateral torso. Prone positioning may be considered if the ap is
to be transferred to the back, buttocks, or posterior lower extremity.

Surface Markings
The triangular space m ust be identi ed and m arked to be
included in the ap dissection (Fig. 57.1). Historically, it has been
Parascapular Cutaneous Axial Flaps
Bruce A. Mast and Richard B. Nesm ith
57
Fig. 57.1 Preoperative marking for parascapular  ap for reconstruction 
after excision of axillary hidradenitis suppurativa.

622
III Masterclasses in Reconstructive Flaps
and adjusted to allow proper mobility of the ap into the recipient
defect (Fig. 57.3).

Important Anatomical
Structures
In 4% of patients, the circum ex scapular artery arises not from
the subscapular artery but independently from the axillary
artery. This eliminates the option for the creation of combination
aps with the latissimus or serratus territories.
Prim ary closure of the donor site is rarely an issue; however,
scarring can be quite noticeable. This should be taken into
account when considering this ap in women and younger
patients (Fig. 57.4).
Occasionally in sm all axillary reconstructions, the size of
the parascapular ap required can be sm all enough to be passed
directly through the triangular space into the axilla.
Step 2: Locating the Pedicle
The loose areolar tissue found in this plane may be followed me-
dially toward the pedicle. The dissection should be carried along
the inferior aspect of the teres minor muscle. A pen Doppler may
be utilized here to assist in locating the emerging vessels.
Step 3: Dissection of the Pedicle
To gain length on the pedicle, the infrascapular branch of the cir-
cum ex scapular artery must be ligated along with minor perfo-
rating branches. If the ap does not include the scapular territory,
the scapular cutaneous artery is ligated at the m edial border of
the ap. At this level of dissection, the pedicle is 5 to 7 cm , while
dissection into the triangle to the origin of the subscapular artery
yields an additional 4 to 7 cm and a larger diameter vessel.
Step 4: Transverse Axillary
Incision
If the dissection within the triangular space proves di cult or if
dissection to the axillary artery is required, then an incision in
the axilla m ay be m ade. The lateral elliptical m ay be carried over
into the axilla or can be planned as a separate incision. Care must
be taken to avoid injury to the extensive neurovascular bundles
in this area including the long thoracic, thoracodorsal, and lateral
thoracic arteries and nerves. However, by com bining this with a
posterior dissection, the creation of a lengthy large-caliber ped-
icle is possible.

Raising the Flap
(as a Pedicled Flap)
Step 1
The incisions are m ade inferiorly starting at the distal tip and car-
ried along the m edial and lateral ap border m arkings for several
centimeters. Subcutaneous dissection is carried away from the
ap edges until the underlying fascia is encountered and divided.
Step 2
The fascia is then elevated and kept in continuity with the skin
ap (Fig. 57.2). The ap is then elevated o of the chest wall.
Often, the descending branch of the pedicle can be auscultated
with the Doppler from the fascial aspect of the ap, con rm ing
proper ap design. If needed, the m ore proxim al incisions can
then be adjusted if the Doppler shows the axial vessel to be
o -center.
Step 3
The m edial and lateral incisions are then carried superiorly as the
ap is elevated o of the chest wall. Flap elevation is continued
Fig. 57.2 Elevation of the parascapular pedicle  ap o  the chest wall.
Fig. 57.3 Reconstruction of the axillary defect.

57 Parascapular Cutaneous Axial Flaps
623
rem ain on its pedicle for axillary and torso reconstruc-
tions. However, large-caliber vessels m ake it suitable for
use as a free tissue transfer to more distant sites.

●
The pedicle is based o branches of the subscapular artery,
which is the largest branch of the axillary artery. Branches
of the subscapular artery include the thoracodorsal artery
and numerous other branches that anastomose with the
lateral thoracic and intercostal arteries. This allows for the
creation of combination aps with the latissimus, serratus,
and/or associated ribs on a single pedicle.

●
The parascapular ap can be used as an osteomyocutane-
ous ap with other composite tissues. If a portion of rib
with the serratus muscle is being considered, then it is
usually part of the sixth rib, whereas a part of the ninth rib
is used when combining with the latissimus dorsi. These
com bination aps are ideal for use in the head and neck
including di cult midface and mandible reconstructions.

●
The ap can be de-epithelialized and used for soft tissue
augmentation in cases of subcutaneous wasting secondary
to external beam radiation or trauma.
Suggested Further Reading
Dabernig J, Sorensen K, Shaw-Dunn J. The thin circum ex scapular artery
perforator ap. J Plast Reconstr Aesthet Surg 2007;60(10):1082
Ellis LZ. Hidradenitis suppurativa: surgical and other management
techniques. Dermatol Surg 2012;38:517–536
Kosutic D, Potter S, Gulic R. Circum ex scapular perforator propeller ap
for axillary reconstruction. Microsurgery 2012;32:251–252
Nassif TM, Vidal L, Bovet JL, Baudet J. The parascapular ap: A new
cutaneous microsurgical free ap. Plast Reconstr Surg 1982;69:591
Sera n D. The parascapular ap. In: Atlas of Microsurgical Composite
Tissue Transplantation. Philadelphia: Saunders; 1996:359

Clinical Perspectives

●
The parascapular ap is an excellent option for skin and
soft tissue coverage to any part of the body. It can be used
for coverage of small to very large defects. The relative uni-
form thickness, non–hair-bearing quality and no donor
site functional morbidity make it an attractive option for
reconstruction.

●
Most commonly, this ap is used for reconstruction of the
axilla, head and neck, or upper extremity. The ap can
Fig. 57.4 Donor site scarring after bilateral parascapular  ap reconstruc-
tion of axillary hidradenitis.

624
Radial Forearm Flaps
Loretta Coady-Fariborzian and W inston T. Richards
58

Classi cation
Fascial, fasciocutaneous, septocutaneous, composite (when includ-
ing radius and/or palmaris longus or exor carpi radialis tendons)

Vascular Pedicle

●
Radial artery (in ow 1.5–3.5 m m ), venae com itantes or ce-
phalic vein (out ow), comitantes have a diameter . 1 mm
close to the elbow

●
Length: can be harvested from takeo of brachial artery as
free ap

●
Sensory innervations: m edial and lateral antebrachial
cutaneous nerves

Patient Positioning
Supine, arm abducted , 90 degrees from shoulder, supinate
forearm.

Surface Markings

●
Measure the defect size; consider adding 10 to 20% to
account for contraction.

●
Doppler/palpate radial artery and mark on skin; design ap
with majority of ap on volar surface of forearm (Fig. 58.1);
prefer to avoid dorsal defect; mark large super cial veins
for use as additional venous drainage from the ap.

●
For free ap, palpate/Doppler radial artery and start 3 cm
proximal to distal wrist crease to avoid exposed distal
tendons (Fig. 58.2).

●
For distally based ap to cover hand defect, mark pivot
point 1 to 2 cm proximal to the radial styloid.

●
Perform Allen’s test to verify patency of palmar arch (57%
of normal hands have radial artery dominance to three or
more ngers).

●
Apply tourniquet to upper arm for better visualization
during ap elevation.

Raising the Flap
Step 1
Incise margins of ap down to and including fascia; suture fascia
to skin to avoid shear stress.
Step 2
Create short longitudinal incisions on either end of the ap over
the radial artery to facilitate identi cation of pedicle.
Step 3
On radial side of dissection, preserve and include cephalic vein.
Step 4
Preserve exor paratenon and radial sensory nerve.
Fig. 58.1 Markings for distally based radial forearm  ap.
Fig. 58.2 Vessel loop surrounding radial artery prior to harvesting for free 
ap.

58 Radial Forearm Flaps
625
Step 11
Cover exposed tendons with super cialis muscle; suture margins
of defect to underlying muscle.
Step 12
Reconstruct new acquired defect with unmeshed split-thickness
skin graft; splint forearm for 5 to 7 days.

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Radial artery

●
Venae comitantes

●
Cephalic vein
Step 5
From radial side, identify and retract radially the brachioradialis
tendon.
Step 6
From ulnar side, identify and retract ulnarly the exor carpi radi-
alis tendon (Fig. 58.3).
Step 7
Take care to preserve the thin intermuscular septum between
the radial artery and the ap; this contains the blood supply to
the ap.
Step 8
Temporarily place an Ackland clamp on the radial artery at
the point of anticipated ligation; verify patency of palm ar arch
(option exists for reconstruction of radial artery with greater
saphenous vein or unused cephalic vein graft, if necessary).
Step 9
Divide intermuscular septum deep to the pedicle; use bipolar to
control perforators to radius and forearm muscles.
Step 10
For free ap, ligate pedicle distally and elevate ap proxim ally
to takeo from brachial artery. For pedicle ap, ligate pedicle
proxim ally (Fig. 58.4) and elevate ap distally to pivot point
(Fig. 58.5).
Fig. 58.3 Hemostat pointing to radial artery.
Fig. 58.4 Hemostat isolating radial artery prior to ligation for distally 
based pedicle  ap.
Fig. 58.5 Distally based radial forearm  ap elevated up to pivot point at 
radial styloid.

626
III Masterclasses in Reconstructive Flaps
Identi ed and preserved:

●
Radial sensory nerve

●
Flexor carpi radialis (FCR)

●
Brachioradialis

●
Paratenon to exor tendons

Clinical Perspectives
Applications include distally based pedicle to cover dorsal hand
defects (Fig. 58.6); proximally based pedicle to cover elbow; and
free ap to reconstruct scalp (Fig. 58.7), contralateral hand, oor
of the mouth, or neck.
Advantages include that they are thin and pliable. Disadvan-
tages include that the donor site can be visible and unsightly; a
possible cold intolerance to ipsilateral hand; and unwanted hair
on recipient site.

Flap Variations

●
Vascularized tendon grafts for reconstruction of dorsal
hand tendons: FCR, palmaris longus (PL), brachioradialis
(Figs. 58.8 and 58.9).

●
Up to 10 cm of vascularized bone and up to 30% of the
cross-sectional area of the radius can be harvested as an
osteocutaneous ap.

●
Can be elevated as adipofascial ap to avoid skin grafting
distal forearm.

Hints and Tips

●
Be cognizant of previous trauma to upper extremity, par-
ticularly arterial lines.

●
If pedicle ap appears congested, then take down ap
and inspect pedicle for kinking, twisting, or compression;
verify that tunnel is adequately wide.

●
Pedicle can be lengthened for distally based flap by m ak-
ing incision over snuffbox, extending to dorsal first web.
Fig. 58.6 Distally based pedicle radial forearm  ap inset over dorsal hand.
Fig. 58.7 (a) Acquired defect of skull and scalp. (b) Radial forearm free  ap reconstruction of acquired defect.
a
b