Grabb’s Encyclopedia of Flaps Head and Neck

CLINICAL RESULTS
Disadvantages of the procedure are the necessity for obstructing vision for 6 to 8 weeks; the lack of a
skeleton (tarsus) in the new lid margin, resulting in a tendency to entropion; the potential for damage to the
lower lid margin; and the absence of lashes in the reconstructed lid.
The functional results of this procedure are excellent. The main objection to the cosmetic result has been
the absence of eyelashes. If this is troublesome to the patient, a cilia graft may be considered as a third
stage. The best donor site is from the eyebrow, but lash grafts are notoriously unsatisfactory. The usual
result is unruly and stubble-like hairs. The patient should understand the uncertainties of lash grafts before,
rather than after, the procedure is done. Artificial lashes are often a superior substitute.
We are aware of one instance where the marginal bridge became necrotic and was lost. This is believed to
be a complication of the pressure dressing rather than a result of the surgical closure of the margin of the
lower lid bridge. Edema of the transplanted tissue has occurred, but it has always subsided with time. We
have seen no failures of the flap to thrive.
Entropion of the reconstructed upper lid margin is not rare. When present, it is often symptomatic and may
result in keratitis. It can usually be corrected by a buccal mucous membrane graft to the lid margin.
SUMMARY
The Cutler-Beard inferiorly based skin-muscle-conjunctival flap from the lower to the upper eyelid is a
simple two-stage operation for the reconstruction of large upper lid defects. It uses a subtarsal full-thickness
flap of the lower lid to fill the upper lid defect.
References
1. Cutler NL, Beard CA. Method for partial and total upper lid reconstruction. Am J Ophthalmol 1955;39:1.
2. Mustardé JC. Repair and reconstruction in the orbital region. Edinburgh: Churchill Livingstone, 1980;140.

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Chapter 25
Modified Tessier Flap for Reconstruction of The Upper Eyelid
J. J. HURWITZ
EDITORIAL COMMENT
This flap accomplishes the objective of total upper eyelid reconstruction, particularly because it utilizes skin
and underlying muscle, which actually improves the viability of the flap, as well as providing sufficient tissue
for restoring the entire horizontal diameter of the upper eyelid.
There are a number of options available for major upper eyelid reconstruction. The flap originally described by
Tessier (1) was a nasojugal flap used in the reconstruction of a total defect in the lower eyelid. However, a
modified Tessier flap (skin-muscle nasojugal flap), combined with a buccal mucous membrane graft, allows for
total reconstruction of an upper eyelid defect. This includes the anterior and posterior lamella, attachment to the
levator aponeurosis so that the eyelid can
move up and down, and provision of an adequate blood supply to the reconstructed eyelid, especially in patients
previously irradiated (2).
INDICATIONS
The modified Tessier flap is especially indicated for major reconstruction of the upper eyelid when the lower
lid cannot be utilized for a bridge graft, if the upper lid has been sacrificed in removing a large tumor, or if it
has been lost due to trauma. The skin-muscle flap described should be lined with mucosa to help form the
posterior lamella of the eyelid. Mucosa is taken from the mouth in the buccal region, but may also be taken
from inside the lip. Alternatively, conjunctiva may be taken from the upper fornix of the contralateral eye, but
this may not be appropriate if the patient has disease in that area, or does not want the uninvolved eye
approached surgically.
ANATOMY
Because the thickness of a flap from the nasojugal area is greater than that of upper eyelid skin and orbicularis,
more stability is provided to the reconstructed lid and this decreases the need for tarsal replacement. Also, the
excellent medial canthal blood supply, particularly the angular artery and some of its tributaries, allows for an
increased length-to-width ratio of the flap. The flap will be rotated to the upper lid to cover a buccal mucosal flap.
The posterior lamella of the eyelid consists of conjunctiva; in this reconstruction, buccal mucous membrane is
chosen for replacement. Buccal mucous membrane is somewhat thicker than conjunctival mucous membrane;
therefore it provides stability to the lid, to a certain extent decreasing the need for any tarsal replacement. For the
anterior lamella, both the skin and muscle of the flap that lie on the superficial aspect of the mucosal graft afford
an adequate replacement.
FLAP DESIGN AND DIMENSIONS
After conjunctival replacement, the modified Tessier flap is developed. An almost vertical flap is marked out in the

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orbitonasal angle and nasojugal region. Its base is centered over the angular vessels and lies above the level of
the medial canthal ligament, allowing the flap to reach 90° of transposition. To rotate the flap into the upper lid,
more torsion is necessary than in rotation to the lower lid; this is achieved by having the upper arm of the flap
base extend more onto the surface of the nose, allowing for rotation into the upper lid and decreasing the
potential for compromise of the circulation due to kinking (see Fig. 25.3).
FIGURE 25.1 Preoperative upper eyelid with basal cell epithelioma.
FIGURE 25.2 A major portion of the eyelid has been resected.
The length of the flap is determined by the length of the defect to be filled; it is useful to have a slightly longer
flap, to allow for potential horizontal shrinkage; extra vertical length will allow for vertical shrinkage as well. It is
suggested that the subciliary incision extend all the way from the flap base to the lateral canthus.
OPERATIVE TECHNIQUE
The malignant tumor is removed under frozen-section control until clear margins are obtained, leaving a virtual
full-thickness total upper eyelid defect (Figs. 25.1 and 25.2). Outlining with a scalpel and then undermining with
scissors, and taking care to avoid the parotid duct opening, conjunctival replacement is first performed with a
posterior lamella graft from the buccal mucosa.
Depending on the size of the graft taken, the cheek may be left open or sutured with 5-0 absorbable material with
a knot buried within the defect. The graft is then harvested and
thinned, and secured with 5-0 running sutures from the upper border to the levator aponeurosis (Fig. 25.3),
which can be identified with the patient opening and closing the eyes, with the white sheet of aponeurosis
moving. If the aponeurosis is difficult to locate, one can dissect to the preaponeurotic fat pad, incise the septum,
reflect the fat superiorly, and the cut end of the levator aponeurosis will then lie directly beneath; 5-0 Dexon
sutures can be used to secure the graft to the lateral and medial edges of the conjunctiva.

FIGURE 25.3 The nasojugal flap has been outlined. Note that the base extends to the nasal skin.
FIGURE 25.4 The flap has been elevated. The mucosal graft is shown sutured into the defect.
A lid-crease incision is made from underneath the punctum (4 mm below), extending laterally to the lateral
canthus. An inferolateral incision is made from the most medial aspect of the subciliary incision; this lateral flap
edge will be the superior edge of the flap in the upper lid. Another incision is made in, or close to, the nasojugal
fold; this medial flap edge will be the lid margin (lower edge) in the upper lid. The two inferolateral incisions are
then joined, the flap undermined, and then rotated into the lid defect (Fig. 25.4). The flap donor site may be
closed with either an advancement flap from the cheek or a free full-thickness skin graft.
If there is lagophthalmos and incomplete closure of the eye, too much of the levator aponeurosis has been
removed. It is then an excellent idea to perform a marginal aponeurotomy before flap placement, by grasping the
levator aponeurosis and placing horizontal incisions in it approximately 3 mm above the cut edge. Then,
horizontal incisions superior to the initial set, but 3 to 4 mm higher, are made. This makes the aponeurosis similar
to an accordion, lengthens it, and allows for better eyelid closure.
FIGURE 25.5 Flap inset. Mucosal graft is in excess.

FIGURE 25.6 Eyelid healed.
The modified Tessier flap is rotated into the upper lid and sutured along its superior and lateral borders (Fig.
25.5). With opening and closing of the patient's eyes, exact determination of the mucocutaneous junction is
possible. The inferior aspect of the mucosal graft can now be trimmed, and the lower edge of flap skin sutured to
the lower edge of graft. Again, it is important that skin does not overhang mucosa, or corneal irritation will result.
Antibiotic-steroid ointment can be placed on the graft and into the palpebral aperture, and a pressure dressing
placed over upper and lower lids, with no undue pressure over the medial canthus area. A protective shield at
night is useful, so that sutures are not disrupted by the patient (Fig. 25.6).
CLINICAL RESULTS
Initially, there may be a small amount of tip ischemia in the flap, but necrosis does not develop. An anterior
conjunctival overhang of the mucocutaneous junction is desirable but, with mucosa shrinking more than the
skin-muscle flap, this overhang tends to decrease with time.
Among the advantages of the modified Tessier flap are that it is a one-stage procedure, scarring occurs
along normal lid folds, the skin is more supple than that of the forehead, and no surgery on the other eyelid
is necessary.
SUMMARY
The flap, combined with a buccal mucous membrane graft, allows for major reconstruction of an upper
eyelid defect, without using the ipsilateral lower lid or the contralateral eye.
References
1. Tessier P. Eyelid reconstruction or blepharopoesis in plastic surgery of the orbit and eyelids. New York:
Masson, USA Inc., 1981.
2. Avram DR, Hurwitz JJ, Kratky V. Modified Tessier flap for reconstruction of the upper eyelid. Ophthal Surg
1988;22:470.

Chapter 26
V-Y-S-Plasty for Closure of A Circular Defect of The Medial Canthal
Area
R. V. ARGAMASO
EDITORIAL COMMENT
This is a most helpful flap, most reliable for defects in the medial canthal area, although it is also applicable
for areas around the lateral aspect of the nose and upper lip. It is superior to the pure advancement flaps.
The V-Y-S-plasty, first reported in 1974 (1), is a simple procedure that conserves tissues and avoids skin
undermining in the repair of round skin defects.
INDICATIONS
Closure of a round skin defect may be accomplished in several ways. When there is laxity in the
surrounding skin, the wound edges are simply approximated in a straight-line closure. More often, some
undermining of skin margins is necessary to reduce tension at the suture lines; dog-ears that form on either
extremity of the line of closure are excised and discarded.
A straight-line scar contracture crossing the valley of the medial canthal area is more likely to bowstring and
simulate an epicanthal fold. In some instances, therefore, a small skin defect in this region is allowed to heal
secondarily. The residual scar may not appear too distracting. In other instances, wound contraction and
spontaneous epithelialization are protracted events, and there is always some risk of displacing the lacrimal
punctum or everting the eyelid. A split-thickness skin graft or a forehead transposition flap may be
acceptable alternatives, despite differences in color match or thickness of skin.
I prefer the V-Y-S-plasty as a procedure for repair of round skin defects that do not lend themselves to
direct approximation of the skin margins without disturbing the neighboring structures of the eyelids. It is a
simple procedure that conserves tissue and avoids skin undermining.
This technique also has been employed in other areas of the face and has been found to be effective in
avoiding disfigurement of symmetrical or paired structures. In addition, this technique has been adapted for
the extremities, where the integument tends to be tense.
FLAP DESIGN AND DIMENSIONS
The lesion is outlined with ink to include a rim of normal skin for tumor clearance. The somewhat circular area to
be extirpated is encompassed by another skin marking, lenticular in configuration and similar to that which one
would use in excision for direct linear closure of the wound (Fig. 26.1A). The axis of this spindle-shaped figure
parallels a natural fold or wrinkle crease.
OPERATIVE TECHNIQUE
The initial incision follows the outline along the rim of normal tissue surrounding the lesion to be removed. Upon
removal of the lesion, two triangular outlines remain, with a circular defect intervening between. These triangles
represent skin that converts into dog-ears if and when the round defect is repaired in linear fashion by drawing

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the opposite wound edges together. Skin advancement at the medial canthal site should be minimized. Tension
affecting the lid skin is more likely to cause eversion of its margin or medial displacement of its punctum.
Additionally, the caruncle may be further exposed. While this outcome may appear to be a minor anatomic
derangement, it can be a source of serious aesthetic concern for the patient. The V-Y-S-plasty resolves this
issue by reserving the dog-ears and developing them into flaps that can be conveniently rotated and advanced
toward each other in the following manner.
A side of one triangle is totally incised, and a short back cut is added at the apex along the skin marking on its
other side. A triangular flap is created, based on one partially intact side. The other triangle is dealt with in a
similar manner, but the relative positions of the incisions are reversed (Fig. 26.1B).
FIGURE 26.1 A: Skin markings for skin excision and sites of the triangular flaps. B: Triangular flaps and
intervening defect. Note that there is no undermining of skin other than the flaps. C: Final closure.
Even with only slight undermining, these flaps will rotate readily to approximately 45° and simultaneously
advance toward each other when their apposing margins are sutured together. It is stressed that no undermining
should be performed on skin beyond the areas demarcated. This point is the essence of the operation.
The sides of the triangles are then sutured to their new positions, and finally, the small secondary defects at the
sites of the back cuts are closed simply by direct skin approximation (Fig. 26.1C).
A single case has been reported (2) in which the dog-ears were saved to fill a round defect. In contrast to the
technique reported here, the triangular flaps were based on the same side (mirror image) and turned over 90°
before they were sutured to each other.
CLINICAL RESULTS
Although one major drawback of the procedure is that some segments of the scar cannot be directed for
camouflage in a wrinkle crease, the result is still superior to a
thin split-thickness skin graft or the thick glabellar flap. Incorporated in this technique are well-established
principles of wound closure in plastic surgery. The procedure is simple, conserves tissue, and avoids skin
undermining (Figs. 26.2 and 26.3). The description “dollar plasty” has been suggested by colleagues, who
envision the scar line as having some resemblance to a stylized dollar sign.

FIGURE 26.2 A: Preoperative skin markings around a pigmented basal cell carcinoma. B: Lesion removed
and flaps prepared. (Continued)
FIGURE 26.2 Continued. C: Repair completed. D: Early result at 2 weeks.
FIGURE 26.3 A: Preoperative skin markings on an elderly man with two adjacent lesions (basal cell
carcinoma). B: One week postoperatively immediately prior to suture removal. Note no demonstrable
alteration in position of canthal structures.

SUMMARY
The melding of the V-Y advancement with the double rotation flaps of the S-plasty enhances the reparative
efficacy of treatment of circular defects, with particular relevance in the medial canthal territory.
References
1. Argamaso RV. V-Y-S-plasty for closure of a round defect. Plast Reconstr Surg 1974;53:99.
2. Fischl RA. A flap for nasolabial defects, or “save the dog-ear.” Br J Plast Surg 1969;22:351.

Chapter 27
V-Y Glabellar Skin Flap to The Medial Canthal Region
J. C. MUSTARDÉ
EDITORIAL COMMENT
This is a very good flap; however, the reader should understand that the forehead glabellar skin is much
thicker than the eyelid skin.
Tumors at the medial canthus are generally basal cell carcinomas, as they are elsewhere on the eyelids, and
they are comparatively slow growing. In the early stages of their development, they may be relatively superficial,
and it may be possible to resect such lesions, along with sufficient normal tissue without the need for deep
dissection. The defect can then be covered by a full-thickness skin graft. An estimate of the depth of the tumor
and the possible involvement of the underlying canaliculi and tear sac may be obtained by injecting a local
anesthetic beneath the tumor to see whether it “balloons” off readily from the deep tissue and by the passage of
a lacrimal probe.
INDICATIONS
In patients in whom it has been determined that the medial canthal lesion cannot be resected superficially,
the degree of hollowing that would be left after an adequate resection would give a poor aesthetic result
with skin graft coverage alone. Indeed, if periosteum and even bone are involved, a skin graft would
probably not survive. A skin flap with a substantial layer of subcutaneous tissue must be used.
FLAP DESIGN AND DIMENSIONS
One of the simplest and most satisfactory techniques for doing such reconstructions is to bring down the thick
glabellar skin as a V-Y flap in a one-stage operation. Depending on the width of skin available between the
eyebrows, a flap designed in the form of an inverted V can be used to cover a defect at the medial canthus of up
to 15 mm in diameter (Fig. 27.1). In conjunction with other flaps, such a flap may be employed to cover even
larger areas. The flap is incised down to the galea aponeurotica, leaving an adequate pedicle on the bridge of
the nose. The vertical dimension of the flap should be about three times the breadth at its lowest part. Once the
flap has been slid down to cover the defect, it will be found that the forehead wound can be closed in the form of
an inverted Y.
V-Y Forehead Flap Combined with Lower Eyelid Reconstruction
Where resection at the medial canthus is carried out with resection of part of an eyelid, it is usually the lower
eyelid that is more involved. If it is not possible to close the lower lid defect by direct approximation of the cut
surface of the tarsal plate to periosteum, a formal cheek rotation flap reconstruction of the lower lid can be
carried out in the manner described in Chapter 13 (Fig. 27.2) (1).
V-Y Flap Combined with Upper Eyelid Reconstruction
Where a medial canthal resection involves a part of the upper lid, and where the upper lid cannot be closed by
direct approximation to periosteum, a V-Y flap can be combined with a cheek rotation flap that carries a small full-

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thickness flap of the lower lid. This small flap is rotated 180° to fill the defect in the upper lid, and the base of the
flap will form the new medial canthus (Fig. 27.3).
OPERATIVE TECHNIQUE
If the resection at the medial canthus has to be laterally extended to include a few millimeters of either or both
eyelids (Fig. 27.4A), the cut surface of the tarsal plates should be sutured to the periosteum at the site of the
medial canthal tendon using a 5-0 Prolene suture. Loss in one or the other eyelid, up to a quarter of eyelid width,
can be dealt with by this technique. Full-thickness loss of more than a quarter of
either eyelid, however, will require additional reconstructive procedures specific to the eyelid or eyelids involved.
FIGURE 27.1 A-D: Provision of flap tissue as cover for deep lesion at medial canthus by means of V-Y forehead
flap. E: Postoperative result 2 years later. (From Mustardé, ref. 1, with permission.)

FIGURE 27.2 A-C: V-Y forehead flap combined with lower lid reconstruction (see Chapter 13). (From Mustardé,
ref. 1, with permission.)
FIGURE 27.3 V-Y flap combined with upper lid reconstruction using a “switch” flap of full-thickness lower lid
rotated into the upper lid (see Chapter 23). (From Mustardé, ref. 1, with permission.) (Continued)
FIGURE 27.3 Continued.

FIGURE 27.4 Deep resection of the medial canthus and resection of the medial end of the upper and lower lids.
A: A probe is inserted into the medial cut end of the nasolacrimal duct. B: Immediate postoperative result. The
defect has been closed by advancing the upper and lower lids toward the midline and by bringing down a V-Y
flap from the glabella. A 3-mm plastic tube keeps the anastomosis between the conjunctiva and the nasolacrimal
duct patent. (From Mustardé, ref. 1, with permission.)
In many patients in whom resection at the medial canthus has to be carried out to a depth that will require
resurfacing by means of a V-Y flap, a part or all of the lacrimal sac also may have to be sacrificed. Provided that
sufficient conjunctiva exists in the fornices, an anastomosis may be done between the upper open end of the
lacrimal sac and the conjunctiva. This is kept patent by a 3-mm-diameter tube of soft plastic, that is left in situ for
2 weeks (Fig. 27.4B).
SUMMARY
The V-Y glabellar flap is an excellent choice for reconstruction of deep lesions of the medial canthal area.
Reference
1. Mustardé JC. Repair and reconstruction of the orbital region, 2d Ed. Edinburgh: Churchill Livingstone,
1980; Chap. 11.

Chapter 28
Forehead Skin Flap for Total Upper and Lower Eyelid
Reconstruction
J. C. MUSTARDÉ
EDITORIAL COMMENT
A considerable number of flaps have been included in this section for historical purposes. Modern surgeons
avoid advancing or stretching tissues for lid reconstruction because of the problem of lid wound contraction.
The multiple-stage procedures also have given way to single-stage methods of reconstruction. Splitting of
the tarsus longitudinally has lost considerable favor because of the inherent difficulties. Closing the eye for
prolonged periods of time (over 10 to 14 days) should be avoided. Prolonged stenting with the use of
tarsorrhaphies was done to prevent wound contraction. The reader is asked to consider simpler procedures
for reconstruction of the eyelids, such as the one presented by McGregor. This shifts similar tissue into the
eyelid area and the advancement is gained by a Z-plasty placed laterally.
Total simultaneous reconstruction of both upper and lower eyelids is rarely required. Technically, the lower
eyelid could be reconstructed by means of a cheek rotation flap lined by a composite graft of nasal septal
mucosa and cartilage. The main problem, however, is reconstruction of the upper lid, because the ideal materials
for carrying out the operation are no longer available. Skin for upper lid reconstruction must inevitably be brought
in as a flap from the periphery of the orbit, and this means skin of a much thicker type than normal eyelid skin.
Lining can be obtained either from the remaining conjunctiva in the fornices or as a free graft of mucosa.
However, the chief difficulty is the absence of muscular activity in the new eyelid, particularly the closing activity
of the orbicularis muscle, but also, to a lesser extent, the lifting action of the levator palpebrae muscle (1).
INDICATIONS
All instances of simultaneous upper and lower eyelid reconstruction reported to this author have been the
result of trauma. The damage to the surrounding tissue, beyond the confines of the lids themselves, has
usually been extensive enough to rule out the immediate use of a cheek rotation flap, even for
reconstructing the lower lid. The problem of producing eyelids that not only will open sufficiently wide to
provide useful vision, but also will close adequately enough to afford a sufficient degree of protection to the
cornea is, indeed, grave in the absence of adequate muscle function. Options open to the surgeon faced
with the problem of having to totally reconstruct both eyelids at one time may be extremely limited.
In such circumstances, and provided a useful eye is still present, the main consideration is the preservation
of the sight in that eye, even if this means occluding it for some considerable time. This is, in effect,
“banking” the affected eye against the possibility that some day the patient will have only one seeing eye. It
can then be exposed and lids constructed that will afford some degree of protection, as well as permitting
the use of the eye itself, even if only to a limited degree.
OPERATIVE TECHNIQUE
The remains of the conjunctiva are dissected from both fornices toward the limbus, so that these thin flaps can

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be turned over the cornea and united by a pull-out running suture. Skin cover can then be obtained by the use of
a midline forehead flap (see Fig. 28.2). A flap of this thickness will provide reasonably adequate support for the
lower lid at a later date and will serve to nourish the conjunctival flaps in the initial stage of the surgery. Two and
a half weeks later, the unused portion of the forehead flap is divided and returned to its normal position (Fig.
28.1A-F).
If the patient has sound vision in the other eye, it may be that no further surgery should be done and the affected
eye can be “banked” against future use, because of the considerable problems encountered in an attempt to
fashion eyelids.
In children who appear to tolerate a greater degree of corneal exposure better than adults, and in adults who
have poor or absent vision in the other eye, the further management of eyelid reconstruction could commence 3
to 4 weeks after division of the flap pedicle.
FIGURE 28.1 A-H: Simultaneous reconstruction of both eyelids (see text for details).

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FIGURE 28.2 Forehead flap that could be used to provide primary cover for both lids. The forehead defect can
be closed directly, and the base of the flap can be returned in 2 weeks. (From Mustardé, ref. 1, with permission.)
A semicircular area of skin and subcutaneous tissue should be excised from the upper half of the flap covering
the eye, down to—but not including—the conjunctival layer, and over an area corresponding to what would have
been the tarsus and preseptal part of the upper lid. The exposed deep surface of the conjunctiva should then be
covered by a full-thickness skin graft taken from behind the ear (Fig. 28.1G), inserting as much excess as
possible. The thinner upper “lid” can be separated from the thicker, stiffer lower “lid” along the line of junction of
the skin graft and flap some 8 to 10 weeks later, when any contraction of the graft that might have developed
should have settled down (Fig. 28.1H). At the same time, the shallow fornices might have to be deepened using
grafts of nasal or buccal mucosa sutured in place between the eyeball and the “lid” as a double layer. Such an
addition to the fornix would almost certainly be necessary to free the globe from the upper lid and allow it to
rotate upward under the lid for protection of the cornea during sleep.
Any remnant of levator palpebrae muscle that was preserved and hitched forward at the time of the original
surgery might produce some slight elevation in the lid, but the probability of this is very slight. A certain amount of
upward lift of the eyelid might be imparted by the action of the frontalis muscle, as in the grossly scarred lids that
result from very deep burns. This, combined with a slight tilting of the head backward, would probably enable the
patient to look out from under the rather inert upper lid and yet allow coverage of the cornea during sleep. The
thick forehead skin on the lower lid should not be interfered with, since this will impart a degree of stiffness to the
lid that will prevent it from drooping.
CLINICAL RESULTS
From my personal knowledge, this procedure has actually been used, with at least some degree of success,
by three surgeons.
SUMMARY
In the very rare circumstance where both upper and lower eyelids need reconstruction, a midline forehead
flap can be used either to “bank” the eye for later use or to create some semblance of eyelids.

Reference
1. Mustardé JC. Repair and reconstruction of the orbital region, 2d ed. Edinburgh: Churchill Livingstone,
1980; Chap. 9.

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Chapter 29
Secondary Superficial Temporal Artery-Neck Flap for Orbital
Reconstruction
H. P. LABANDTER
B. GUYURON
EDITORIAL COMMENT
This is an excellent technique for eye socket reconstruction. However, there are two limiting factors: (1) the
length of the temporal artery, and (2) the size of the defect. If the defect is too far medial or too large, the
procedure may not be able to line the eye socket completely.
Eye socket reconstruction using skin or mucosal grafts and flaps has been notoriously difficult because of
scarring, contracture, and donor deformities (1, 2). The ideal reconstruction should be done with hairless tissue,
cause minimal donor-site deformity, and provide sufficient tissue for adequate prosthetic reconstitution.
Experimental work has demonstrated the possibility of vascularizing tissue such as skin flaps and even
composite flaps by the introduction of known axial vessels using omentum (3, 4). Experimental and clinical work
has shown that a random-pattern flap can be converted into a “secondary” axial-pattern skin flap on a known
vascular supply (5). The superficial temporal artery can be placed beneath the hairless skin below the ear. Once
vascular connections have been established, the flap can be transferred to cover various areas of the face within
the arc of flap rotation.
INDICATIONS
Advantages of the procedure not only include the use of a known axial-pattern flap of hairless skin, but
there is also no flap contracture, donor-site deformity is minimal, and a deep reliable sulcus for prosthetic
placement can be established.
ANATOMY
The area to be used as lining for the eye socket is situated below and posterior to the tragus of the ear and is a
patch of hairless skin. A site is selected where the donor area scars can be hidden, if possible, by hairstyling. In
the adult male, the area of skin is limited to the space between the beard and the hairline, approximately 3.5 × 4
cm in width. Vertically, the distance can be extended as needed.

FIGURE 29.1 A: Vascular pedicle extending superiorly. B: Vessels pivoted downward toward the skin flap. C:
Vessels buried under the skin flap. D: The arc of rotation. E: Flap in situ with donor area closed.
The superficial temporal artery, which is a terminal branch of the external carotid, begins in the parotid gland
behind the neck of the mandible and crosses over the posterior root of the zygomatic arch. About 5 cm above the
arch, it divides into an anterior and posterior branch. The frontal anterior branch runs upward and forward in a
tortuous fashion, supplying muscle, skin, and pericranium in that area. The posterior parietal branch is larger
than the anterior branch, curving upward and backward on the side of the head, lying superficial to the temporal
fascia, and anastomosing with the opposite artery and the posterior auricular and occipital arteries. Variations in
the superficial temporal arteries include differences in the relative sizes of the frontal and parietal branches.
Either of these may be absent. The maximum length of the posterior parietal branch will be used as “donor”
vessels for this flap.
FLAP DESIGN AND DIMENSIONS
The pivot point of the flap lies at the superior end of the tragal notch, at about the level of the zygomatic arch.
The vascular pedicle extends superiorly for a distance of 8 to 10 cm. From this point, extending across the face
to the medial end of the orbit would be approximately the same distance (Fig. 29.1A). The vessels are lifted
together with a fascial envelope to protect the microvasculature and are inserted inferiorly under a trapdoor of
skin measuring approximately 3.5 × 4 cm (Fig. 29.1B). Variations in the exact site and size of the skin disk can be
tailored according to the amount of skin required to line the socket, the amount of hairless skin readily available,
and how much can be removed and still allow direct closure of the donor site (Fig. 29.1C).
The arc of rotation for practical use is 180° to 200° extending superiorly to 3 to 4 cm above the helix of the ear,
medially to the medial canthus, and inferiorly down to the upper part of the sternocleidomastoid and postauricular
area (Fig. 29.1D).
OPERATIVE TECHNIQUE

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Donor Site
Measurement is made from the medial canthus to the pivot point of the superficial temporal vessels just above
the zygomatic arch to determine the length required. The skin is opened through a preauricular incision at face
lift level, and an anterior flap is developed. The incision is extended upward superiorly for 6 to 8 cm to identify
the superficial temporal artery and vein under the fascia.
By careful dissection using magnifying loupes, the artery and vein are traced up superiorly and posteriorly as far
as possible, maintaining a good connective-tissue sheath. Above the top of the helix, the area around the
vessels is expanded into a fascial paddle (Fig. 29.1B) so that the proximal half of the buried portion of the
vessels is encased in a protective fascial
layer together with the microvasculature surrounding the vessels. This paddle may be made as large as 2 × 2
cm.
The entire fascial paddle and vessels are then carefully raised and pivoted downward to see how comfortably
they lie over the proposed skin area on the side of the neck. The desired ellipse of skin is tested for ease of
direct closure by moving the head and palpating between fingers. The appropriate area is marked out in a
transverse or vertical direction. Three sides of the skin may be raised as a trapdoor to join the preauricular
incision (Fig. 29.1C).
Three weeks following this procedure, the entire skin paddle is raised carefully to subcutaneous level and freed
together with the vascular pedicle. The preauricular incision is opened, and using face lift scissors, a wide tunnel
is created toward the lateral aspect of the eyelid commissure.
Recipient Site
The lining tissue is opened transversely, and the sulcus is deepened by sharp and blunt dissection superiorly
and inferiorly. When this has been completed, there may be sufficient mucosa to serve as adequate lining to the
lids, or the inner parts of the upper and lower lids can be lined with a full-thickness skin graft from behind the ear.
The pedicle is then tunneled subcutaneously, and the skin is laid into the posterior aspect of the socket (Fig.
29.1E). Care must be taken not to constrict the vessels and to avoid kinking. The use of fluorescein and a
Doppler probe helps to verify the viability of the flap and the patency of the vessels. A drain is used throughout
the cheek, emerging in the neck area. The face is closed in layers, and the flap in the posterior aspect of the
socket can be tacked down loosely or fitted superiorly and inferiorly with tie-over bolsters coming through the
superior and inferior sulcus of the eyelids (Fig. 29.2).
CLINICAL RESULTS
That this is a two-stage procedure, that in some cases limited skin is available in adult males, and that
visible scars may be a problem, are among the disadvantages of this procedure. In addition, extremely
careful dissection of vessels is required. The second stage at 2 to 3 weeks must be done with care, and
any kinking or hematoma may compromise the vascularity of the flap. Extended musculofascial flaps, free
flaps, and even tubed pedicle flaps have been used, but all have multiple disadvantages.
SUMMARY
This is a useful technique for acquiring hairless skin from the neck and postauricular areas when a deep
permanent eye socket is needed for prosthetic placement.

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FIGURE 29.2 A: A 14-year-old girl who had undergone an exenteration of the left orbit for retinoblastoma.
She could not maintain an adequate prosthesis in the contracted eye socket. B: Vessels in situ under 3 × 4
cm skin flap at three weeks. C: Skin paddle to be inserted into the posterior aspect of the socket. D: Bolster
sutures attaching flap to superior and inferior aspects of the eyelid. E: Postoperative result showing deep,
well-lined socket. (Continued)
FIGURE 29.2 (Continued). F,G: Preoperative (left) and postoperative (right) views of patient revealing a
functional eye socket with reasonable symmetry.
References
1. Mustardé JC. The orbital reconstruction. In: Mustardé JC, ed. Plastic surgery in infancy and childhood, 2d
ed. Edinburgh: Churchill Livingstone, 1979.

2. Soll DB. Anophthalmic socket surgery. Int Ophthalmol Clin 1978;18:169.
3. Erol OO, Spira M. Development and utilization of composite island flap employing omentum: experimental
investigation. Plast Reconstr Surg 1980;65:405.
4. Erol OO. The transformation of a free skin graft into a vascularized pedicled flap. Plast Reconstr Surg
1976;58:470.
5. Yao S. Vascular implantation into skin flap: experimental study and clinical application. A preliminary
report. Plast Reconstr Surg 1981;68:404.

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Chapter 30
Postauricular Fasciocutaneous Island Flap
B. GUYURON
H. P. LABANDTER
Dissatisfaction with the available modalities for eye socket reconstruction, particularly in an irradiated and
previously operated field, prompted us to look for another alternative. Following much preplanning influenced by
Washio's work (1, 2), and after considerable cadaver dissections, clinical trials, and staged procedures, we came
to the conclusion that a postauricular fasciocutaneous island flap can successfully be transferred for the
correction of certain difficult defects (3).
INDICATIONS
The postauricular fasciocutaneous flap can be used for defects of the forehead, eye socket, lateral nose,
cheeks, and commissure area. It can even be used for intraoral defects in the buccal sulcus area or the
palatal region. An invaluable indication for this flap is the Treacher Collins syndrome, which usually
represents a very difficult reconstructive challenge.
Hematoma, infection, partial flap loss, and injury to the temporalis branch of the facial nerve are all
theoretical complications of this flap. However, in our experience, there were only two small superficial
losses of the distal portions of the flaps, and both healed without further difficulties. The disadvantages of
this flap include tedious dissection and a limited amount of available skin, which make it unsuitable for large
defects. Occasionally, a split-thickness skin graft is needed to cover the donor-site defect.
This flap provides an adequate amount of skin and soft-tissue bulk for reconstruction of a missing eye
socket and orbital area. The color match is close to the facial color for extended reconstruction. Being non-
hair-bearing, the skin can be used to replace missing conjunctiva or mucosa. The donor defect can usually
be closed primarily or with a small skin graft, which is usually not visible.
ANATOMY
Even though the useful cutaneous portion of the flap receives a random-pattern circulation from the posterior
branch of the
superficial temporal vessel, the whole flap, including the triangular piece of dermis and the temporalis fascia, is
raised as an island flap. Therefore, the arterial supply comes from the superficial temporal artery and the
posterior branch of this vessel and then through the subdermal plexus reaching the cutaneous portion, which
after passing through the capillary returns through the posterior branch to the superficial temporal vein.
FLAP DESIGN AND DIMENSIONS
This flap has three distinct anatomic components: the skin, dermis, and fascial portion, which encompasses the
postauricular vessels. The cutaneous portion of the flap is the non-hair-bearing skin of the postauricular area.
This portion can be as large as 5 × 6 cm. The dermis portion is a triangular-shaped area located cephalad to the
upper pole of the helix at the base of the triangle positioned caudally (Fig. 30.1A). The base of this triangle is
attached to the upper border of the postauricular skin to be transferred as a flap. This triangular deepithelialized
area is approximately 6 cm long in a cephalocaudal direction, and it contains the posterior arterial and venous

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branches of the superficial temporal vessels. The third portion of the flap is the temporalis fascia just anterior to
the triangular de-epithelialized skin of the scalp encompassing the superficial temporal artery and vein. This
fascia is rectangular in shape, and its anterior boundary is about 5 to 10 mm anterior to the superficial temporal
vessels. The posterior limits are de-epithelialized triangular skin, which extends cephalad up to 6 or 7 cm from
the upper pole of the helix. The caudal limit is at the upper border of the zygoma, where it is often detached to
allow freedom of movement for the vascular pedicle.
FIGURE 30.1 A: The three different portions of the postauricular island flap: postauricular skin, de-epihelialized
supra-auricular scalp, and temporalis fascia encompassing the superficial temporal vessels. B: The arc of
rotation of the postauricular flap. C: The incision in the postauricular area, which includes the non-hair-bearing
skin of the retroauricular region. D: The triangular portion of the flap is designed by connecting the most superior
and posterior portions of the skin flap to a point about 6 cm cephalad to the upper pole of the ear. A vertical line
from this point to the upper pole of the ear will then outline the anterior limb of the triangle. E: The mobilized flap
and donor effect. Please note the cutback incision that has been made between the triangular flap and the
vascular pedicle to augment the reach of the flap. F: The donor-site and preauricular skin closure with the flap
delivered to the orbit through a subcutaneous tunnel. (From Guyuron, ref. 3, with permission.)
This flap can be rotated 360°, the pivot point being located at the level of the tragus. This flap will have a radius
of about
14 cm. However, the useful rotation of the flap extends from the forehead area down to the mandibular angle,
including the oral commissure and the lateral nasal area. This flap can be used for reconstruction of palatal
defects (Fig. 30.1B). The postauricular portion of the flap includes non-hair-bearing skin of the retroauricular
region, leaving 6 to 7 mm of skin along the ear margins (Fig. 30.1C). To design the posterior limb of the

triangular flap, a line is drawn 6 cm cephalad to the upper pole of the ear to the most cephalad portion of the
postauricular skin flap. The base of the triangular flap will be the superior edge of the cutaneous flap, and the
anterior limit is a line 1 cm anterior to the palpable superficial temporal vessels.
OPERATIVE TECHNIQUE
A postauricular incision is made, and the skin flap is raised, including the underlying superficial fascia. Extreme
care is exercised to leave the perichondrium intact. Inferior, anterior, and posterior outlines of the skin flap are
included in this incision, leaving the superior portion attached to the triangular flap. The incision along the
anterior border of the triangular portion is carried through the skin with great caution to avoid injury to the
superficial temporal vessels just beneath the skin. This incision is continued along the preauricular fold much like
a face lift incision. Next, the posterior incision is made through the skin as well as the fascia.
The identification and separation of the superficial temporal vessels from the overlying skin are now undertaken.
The temporalis fascia, encompassing the superficial temporal vessels, is left attached to the vessels. To ensure
vessel safety, the fascia is incised 10 mm anterior to the vessels. The triangular temporalis fascia flaps are
raised off the temporalis muscle together. The vessels are dissected proximally to the point where they enter the
parotid gland. These tortuous vessels can be dissected to give considerable length to the pedicle.
FIGURE 30.2 A: Preoperative photograph of a 10-year-old boy following enucleation and radiation of the left
orbit and a previously failed attempt at eye socket reconstruction. B: Two years following eye socket
reconstruction using the postauricular fasciocutaneous technique. C: After reconstruction, the eye socket is
supple and functional. (From Guyuron, ref. 3, with permission.)
If the flap is being used for an eye socket reconstruction, a subcutaneous tunnel is then created carefully to
preserve the integrity of the temporalis branch of the fascial nerve. When the dissection reaches the lateral
orbital wall, it should be continued in a subperiosteal plane to preserve the lateral canthal attachments to the skin
and upper portion of the periosteum.
The triangular portion of the flap is then de-epithelialized, and the reach of the flap is measured (Fig. 30.1E). If
further length to the pedicle is needed to allow the flap to reach the medial canthal region, a cutback incision is

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made between the pedicle and the triangular flap starting caudally, close to the origin of the vascular pedicle. As
much as an inch of the pedicle can be separated safely from the triangular flap, leaving from 3.5 to 4 cm of the
pedicle attached to the triangular portion of the flap (Fig. 30.1E).
Although the flap often looks slightly congested, it usually recovers in a few hours. The flap donor area in the
postauricular region is covered with a split-thickness skin graft if necessary, and tie-over sutures are used. The
rest of the donor-site incision is closed by approximation of the skin (Fig. 30.1F).
CLINICAL RESULTS
This flap has been used successfully in 15 patients to reconstruct missing or contracted eye sockets (Fig.
30.2). It has been used in two Treacher Collins patients to reconstruct the soft-tissue deficiency in the malar
area, for reconstruction of a palatal deformity in one patient, and for the reconstruction of a total lower
eyelid in another patient.
SUMMARY
A flap of postauricular skin based on the superficial temporal vessels and surrounding fascia is described.
This flap is excellent for reconstruction of missing or contracted eye sockets or for small to medium-sized
facial defects such as on the eyelids or for internal defects.
References
1. Washio H. Retroauricular-temporal flap. Plast Reconstr Surg 1969;43:162.
2. Washio H. Further experiences with the retroauricular temporal flap. Plast Reconstr Surg 1972;50:160.
3. Guyuron B. Retroauricular island flap for eye socket reconstruction. Plast Reconstr Surg 1985;76:527.

Chapter 31
Arm Skin Flap for Orbital Socket Reconstruction
M. R. WEXLER
I. PELED
EDITORIAL COMMENT
This procedure, particularly in an irradiated patient, could be more easily and safely accomplished using a
microvascular transfer of the radial forearm skin, with anastomosis at a site distant from the irradiated area.
Reconstruction of a contracted or missing socket, even when the eyelids are present, is a difficult problem (1). In
several patients who undergo exenteration and irradiation, the socket does not exist, and in others, it cannot be
stretched because of fibrosis. Young patients generally resent the idea of an external prosthesis. An upper arm
flap supplies a thin piece of skin that can be used for reconstruction of both the inner lining of the eyelids and the
socket lining, so that it can accommodate a prosthetic eye (2).
INDICATIONS
Bringing a distant flap into the orbit solves several problems. First, it lines the socket with good, durable skin
that can hold a prosthesis and has no tendency to shrink. Second, the hollowness of the orbit is overcome
by the introduction of the flap tissue. Third, there is the hypothetical possibility of movement if a temporalis
muscle transfer can be carried out between the two layers of the reconstructed eyelids.
Although adults will generally prefer outer cosmetic prostheses, the opposite seems true in children.
Although the end result is far from perfect, children seem to need the self-confidence of having restoration
of the body image in order to lead more normal, active lives.
Patients who have had orbital irradiation present the problem of a contracted socket that is complicated by
fibrosis, atrophy of the tarsal plate, loss of lashes, and obstructed canaliculi (3) (Fig. 31.1). The lack of
tissue for intraocular prosthesis coverage, poor function of the eyelid remnants, higher susceptibility to
trauma, and slower healing also escalate the risk of complications. Many patients who undergo orbital
exenteration for tumor removal will have a temporalis muscle transfer for coverage of an intraocular
prosthesis or for filling the hollow orbit. It seems more reasonable to preserve this precious muscle as a
motor (4) in the case of diminished eyelid movement resulting from the operation, irradiation, or both. It is
urged, therefore, that surgeons consider all possible alternatives before using this muscle.
FLAP DESIGN AND DIMENSIONS
A bipedicle Tagliacozzi flap (5) is marked along the anteromedial aspect of the arm. The ipsilateral arm is chosen
for reconstruction of the socket. The flap may extend along the arm and reach 15 × 10 cm in size.
OPERATIVE TECHNIQUE
After the two parallel incisions are made along the medial aspect of the arm, the bipedicle flap is raised by
dissecting it in the areolar tissue above the fascia. The edges are sutured together to form a tube. If possible, the
donor site is closed by direct suture, but generally, it is advisable to cover it with a skin graft. The first step might

be limited to incision and elevation of the bipedicle flap and resuturing it back in place as a delay.
Five days following the construction of the tubed flap, we place a rubber band constricting the proximal base of
the flap two or three times a day for 15 minutes to enhance the blood supply through the distal end. Capillary
filling can be tested by injecting fluorescein intravenously, and then between the tenth and fifteenth day it must
be decided when to incise the proximal end and insert the flap in the orbit. The end of the flap is partially de-
epithelialized in order to bury it in the posterior orbit. The approach to the orbit is through an incision in the
eyebrow or lateral canthal region or through an old scar (Figs. 31.2 and 31.3B).
The remnants of the eyelids anteriorly are dissected from the orbital scar tissue. Most of the portion of the tubed
flap to be inserted in the orbit is de-epithelialized, except for the skin island (Fig. 31.3B) on which the posterior
surface of the ocular prosthesis will rest. The end of the flap is held in the orbit by sutures tied over bolsters (Fig.
31.2). The forearm is held to the head using elastoplast.
FIGURE 31.1 A: Eight years following orbital exenteration and irradiation for the treatment of retinoblastoma. B:
Following reconstruction of right orbital socket. The part of both eyelids close to the lateral palpebral fissure is
skin from the turned-over, defatted portion of the arm flap. (From Wexler et al., ref. 2, with permission.)
FIGURE 31.2 A patient who had retinoblastoma of the left eye at the age of two months. As an adult, he
underwent augmentation of the orbital contents using the arm flap. The elastoplast “cap” splint and its extension
to the hand immobilize the arm. This is released every third day for physiotherapy of the elbow, and then the arm
is immobilized again. (From Wexler et al., ref. 2, with permission.)

FIGURE 31.3 A: This patient had a retinoblastoma and underwent exenteration of the left eye at the age of 8
months. He had radiotherapy to the orbit as well. B: The arm flap before its introduction into the orbit. The oval
skin island serves as a lining for the posterior pocket, while the de-epithelialized part fills the orbit. The eyelids
were sutured together for 1 month. The flap will be divided in 2 weeks, defatted, and turned upon itself to provide
the posterior lining of the eyelids. C: Lateral view 2 years postoperatively. There is no movement in the eyelids.
(From Wexler et al., ref. 2, with permission.)
Starting on the fifth day, a rubber band tourniquet is applied to the tubed flap near the elbow, where it will
eventually be divided, for 10 to 15 minutes two to three times a day. When circulation proves to be adequate, the
flap may be severed. The base of the tubed flap is untubed and sutured back to the arm. The several-
centimeter-long tube protruding from the facial skin is defatted so that its skin edges can be sutured closed. Two
days later, this long end of the tubed flap is opened and defatted, leaving a thin flap of skin supplied only by its
subdermal plexus. The original approach into the socket is used to introduce this distal skin flap, which is now
turned upon itself to line the posterior aspect of the eyelids.
Modifications of this method can be adapted to different patients. The flap could be used just as filling material in
the hollow orbit, thus supplying the retrosocket with supple tissue, or as filling material over the temporal region.
False eyelashes can be glued on the reconstructed lid margins.
SUMMARY
The Tagliacozzi or arm skin flap can be used to provide both lining and bulk in orbital socket reconstruction.
References
1. Smith B, Valauri AJ. The orbit. In: Converse JM, ed., Reconstructive plastic surgery, 2d ed. Philadelphia:
Saunders, 1977;962-970.
2. Wexler MR, Peled I, Kaplan H. Socket reconstruction using cross-arm flaps. Plast Reconstr Surg
1981;68:18.
3. Merriam AR. Radiotherapy of tumors of the lids. In: Tessier P, Callahan A, Mustardé J, Salyer K, eds.,
Symposium on plastic surgery in the orbital region. St. Louis: Mosby, 1976;339.
4. Rubin LR. Entire temporalis muscle transposition. In: Rubin LR, ed., Reanimation of the paralyzed face.
St. Louis: Mosby, 1977;294.

5. Gnudi MT, Webster JP. The life and times of Gaspare Tagliacozzi. New York: Herbert Reichner, 1950.

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Chapter 32
Reverse Temporalis Flap for Reconstruction After Orbital
Exenteration
N. MENON
R. SILVERMAN
EDITORIAL COMMENT
The temporalis muscle is an excellent local flap to fill the exenterated orbit. The authors' suggestion of
making an adequate orbitotomy to pass the muscle has the advantages of shortening the arc of rotation and
avoiding an osteotomy of the lateral orbital rim. The secondary depression in the temple can be filled as the
authors indicate with either allograft or dermal-fat grafts.
Orbital exenteration usually involves the resection of the entire contents of the orbits, with or without resection of
the eyelids. Techniques to replace the orbital contents with vascularized tissue have involved multiple stages or
have included the use of microvascular techniques. This chapter introduces the reader to a single-stage pedicled
transposition of the temporalis muscle into the orbital cavity through a window created in the lateral orbital wall.
INDICATIONS
Techniques to replace the orbital contents with vascularized tissue have included pedicled flaps
(retroauricular island flap, cheek flap, pectoralis flap) (1, 2, 3) and free flaps (radial forearm, dorsalis pedis
flap) (4, 5, 6). A single-stage pedicled transposition
of the entire temporalis muscle as a pedicled flap into the orbital cavity, through a window created in the
lateral orbital wall, can be accomplished in any patient who has undergone orbital exenteration and has an
intact ipsilateral temporalis muscle. This single-stage technique provides the muscle bulk needed to
obliterate the orbital cavity, and provides a vascularized soft-tissue cover around the exposed bone and
subjacent sinus cavities.
ANATOMY
The temporalis muscle is a fan-shaped muscle located on the lateral aspect of the skull. It originates along the
inferior temporal line on the cranium. The deep temporal fascia covers both the superficial and the deep (cranial)
aspects of the muscle. The deep temporal fascia joins the periosteum of the cranium along the superior temporal
line (temporal crest). The muscle lies in the temporal fossa and inserts on the mandible after passing along the
deep surface of the zygomatic arch (7). The muscle inserts on the coronoid process and along the anterior
ramus of the mandible. The muscle is innervated by the mandibular branch of the trigeminal nerve (cranial nerve
V). Contraction of the muscle causes retraction and elevation of the mandible (7).
The muscle is supplied by two dominant vascular pedicles and a minor pedicle, making it a type III muscle
(Mathes and Nahai classification) (7). The dominant pedicles are the anterior and posterior deep temporal
arteries, both of which are branches of the internal maxillary artery. The deep middle temporal artery (branch of
the superficial temporal artery) forms the minor vascular pedicle (2). The venous drainage of the muscle is

through the venae comitantes that accompany the arterial supply.
Both dominant vascular pedicles are located on the deep surface of the muscle at the level of the zygomatic arch
within a centimeter of each other. On the other hand, the minor pedicle is located on the superficial surface of the
muscle in the preauricular region just cephalad to the zygomatic arch (7).
FLAP DESIGN AND DIMENSIONS
The temporalis muscle can be transposed as a pure muscle flap or as a musculocutaneous flap. It is best to use
the temporalis as a pure muscle flap, as taking the skin paddle along with the muscle would leave an
unacceptable donor scar with a significant amount of alopecia (7). The vascular supply configuration allows the
muscle to be split coronally (into anterior and posterior halves) or sagittally (into deep and superficial halves) (8).
In this application, transposition of the muscle en bloc provides total fill of the orbital cavity in a safe, expedient
manner. Furthermore, with muscle-splitting techniques, there is a real risk that the pedicles could be damaged
during the dissection.
In a limited cadaver study, three parameters were measured to quantify the crucial dimensions involved in the
operation: (a) the height of the temporalis from the zygomatic arch to the point most superior on the inferior
temporal line, (b) the width of the temporal fossa from the point most anterior to the point most posterior on the
inferior temporal line, and (c) the dimensions of the bony window in the lateral orbital wall needed to pass the
muscle without compression (9). The mean height was determined to be 8.45 cm, whereas the mean width was
determined to be 10.5 cm (9). The mean dimensions of the bony window in the cadaver study were found to be
3.3 cm × 1.9 cm (9).
OPERATIVE TECHNIQUE
Tissue Planes and Anatomic Landmarks
The coronal or hemicoronal incision provides the most access and exposure of the temporalis muscle. A stealth
incision can camouflage the postoperative scar on the scalp. It is better to use Raney clips for hemostasis along
the scalp edges rather than electrocautery, so as to minimize alopecia along the scar edges. Electrocautery can
be used to dissect through the subcutaneous tissue until a loose areolar plane is reached. The subsequent
plane over the temporal region will be the superficial temporal fascia (also called the temporoparietal fascia); the
corresponding plane over the cranium would be the galeal plane. Dissection through the superficial temporal
fascia reveals the glistening white, deep, temporal fascia that envelops the temporalis muscle; division of the
galeal plane should reveal the periosteum of the cranium.
After exposure of the deep temporal fascia inferolaterally and the periosteum of the skull medially, the scalp can
be mobilized anteriorly, to provide exposure to the zygomatic arch and the lateral orbital rim. The periosteum is
incised medial to the temporal crest, and a subperiosteal dissection is performed inferolaterally, to elevate the
temporalis muscle from the temporal fossa and to detach the muscle from its origin. Care must be taken to
ensure that the dissection remains in a subperiosteal plane (especially laterally around the region of the
zygomatic arch), as the two major pedicles to the muscle flap lie on the deep (cranial) surface of the muscle. The
insertion of the muscle on the coronoid process of the mandible is maintained, as it provides a convenient point
of rotation; greater mobility and range of transposition can be achieved if the insertion is taken down, but in most
instances this is unnecessary. Furthermore, because both dominant pedicles are located on the deep (cranial)
surface of the muscle very close to its insertion, the risk of damaging the pedicles may not justify the gain in
mobility.
A burr is used to make a window in the lateral wall of the orbit (orbital surface of the zygomatic bone), and
rongeurs can be used to make the window large enough to pass the entire temporalis muscle. The window
should be made large enough to pass the muscle without causing any compression.

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One alternative to a lateral wall orbitotomy is to transpose the temporalis muscle over the lateral orbital rim and
into the orbital cavity. However, we believe this option is less desirable, as it is more difficult to fill the entire orbit
and to secure the muscle inside the orbit. Furthermore, on closure, the transposed muscle can be compressed
between the skin flap and the lateral orbital rim, which could potentially cause arterial or venous insufficiency.
Distorting of the transverse dimension and the upper face contour is an additional drawback of this technique.
Another alternative to the lateral wall orbitotomy is a lateral rim osteotomy. An osteotomy can be made on either
side of the zygomaticofrontal suture, and after transposition of the temporalis into the orbit, the bony rim fragment
can be fixed with a miniplate and screws. The drawback of this technique is that the periosteum and
microvasculature within the cortex of the lateral rim are disrupted on performing the osteotomy. Because patients
who undergo orbital exenteration are likely to receive or have already received radiation therapy, disrupting the
vasculature increases the risk of developing osteoradionecrosis of the lateral rim, with concomitant exposure of
the fixation system.
FIGURE 32.1 Preoperative right orbital defect after orbital exenteration.

FIGURE 32.2 The temporalis muscle has been reflected laterally to expose the deep surface of the muscle. The
Penrose drain passes through the window created in the lateral orbital wall.
CLINICAL RESULTS
Depicted here is an example of a 74-year-old man who presented 6 months after orbital exenteration for
ocular melanoma (Fig. 32.1). At presentation, he had exposed bone, with communication into the paranasal
sinuses and chronic drainage from the orbit. After thorough debridement of the orbit, the temporalis muscle
was exposed, using a coronal incision up to the lateral orbital rim and zygomatic arch (Fig. 32.2). After
creation of a window in the lateral orbital wall, the temporalis was then detached from its origins and
transposed into the orbit through the window in the lateral orbital wall. The muscle flap was inset into the
orbit, sutured to the surrounding skin edges, and covered with a nonmeshed split-thickness skin graft.
Postoperatively, the patient had a well-healed right orbit with no drainage (Fig. 32.3). The patient reported
no problems with mastication or motion of the mandible. A contour defect in the right temporal fossa was
noticeable, and the patient underwent placement of a porous polyethylene implant to fill in the contour
defect 9 months after the original operation. The patient has subsequently done well. At this time, the
authors prefer the immediate use of layered allograft (LifeCell Corp., Branchburg, NJ) in order to fill in the
donor-site defect. This can be done at the time of the initial operation, due to the ability of allograft to
become revascularized and therefore to resist infection (10). The donor-site contour defect can also be
addressed with the use of dermal-fat grafts.

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FIGURE 32.3 Anteroposterior (AP) view at 7 months postoperatively, showing well-healed reconstruction.
SUMMARY
The temporalis muscle can be used as a pedicled flap for reconstruction after orbital exenteration in a one-
stage operation. After transposition, the entire muscle can be used to fill the orbit and to provide a vascular
bed for an onlay split-thickness skin graft. Preservation of the lateral orbital rim allows for retention of the
transverse width and anterior projection of the upper face. Transposition of the temporalis has minimal
effect on mastication, as the other muscles of mastication compensate adequately. The contour defect in
the temporal fossa can be corrected by either allograft or synthetic implant, depending on the risk of
infection.
References
1. Ariyan S. Pectoralis major, sternomastoid and other musculocutaneous flaps for head and neck
reconstruction. Clin Plast Surg 1980;7:89.
2. Matsumoto K, Nakanishi H, Urano Y, et al. Lower eyelid reconstruction with a cheek flap supported by
fascia lata. Plast Reconstr Surg 1999; 103:1650.
3. Guyuron B. Retroauricular island flap for eye socket reconstruction. Plast Reconstr Surg 1985;76:527.
4. Weng CJ. Periorbital soft tissue and socket reconstruction. Ann Plast Surg 1995;34:457.
5. Tahara S. Eye socket reconstruction with free radial forearm flap. Ann Plast Surg 1989;23:112.

6. Thai KN, Billmire DA, Yakuboff KP. Total eyelid reconstruction with free dorsalis pedis flap after deep
facial burn. Plast Reconstr Surg 1999;104:1048.
7. Mathes SJ, Nahai F. Reconstructive surgery: principles, anatomy and technique, vol. I. St. Louis: Quality
Medical Publishing, 1997;386-396.
8. Holmes A, Marshall K. Uses of the temporalis muscle flap in blanking out orbits. Plast Reconstr Surg
1979;63:336.
9. Menon NG, Girotto JA, Goldberg NH, Silverman RP. Orbital reconstruction after exenteration: use of a
transorbital temporal muscle flap. Ann Plast Surg 2003;50:38.
10. Menon NG, Rodriguez ED, Byrnes CK, et al. Revascularization of human acellular dermis in full-thickness
abdominal wall defects in the rabbit model. Ann Plast Surg 2003;50:523.

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Chapter 33
Microvascular Free Transfer of A First Web Space Skin Flap of The
Foot to Reconstruct The Upper and Lower Eyelids
L. A. CHAIT
The reconstruction of both upper and lower eyelids when their total loss accompanies orbital exenteration is
difficult (1, 2). This deformity may result from tumor excision or trauma. For this reason, the use of a prosthesis
that is either applied directly over the cavity or attached to spectacles is often advised. However, patients
sometimes request reconstruction (Fig. 33.1).
INDICATIONS
The neurovascular free flap from the first web space of the foot has been invaluable in reconstructing both
upper and lower eyelids in these instances (3, 4). The texture of the dorsal skin of the toes and the color
match are found to be acceptable. The web itself forms a natural lateral canthus, and the thicker plantar
skin gives enough support to maintain a light prosthesis. Crude sensation returns to the outer part of the
flap. At first, this is referred to the temporal region, but later it tends to reorient to the eyelid itself. Both skin
cover and lining for each of the upper and lower lids are provided in a single operation, and much of the
scarring that results from local flap reconstruction can be avoided.
ANATOMY
See Chapter 335.
FLAP DESIGN AND DIMENSIONS
The flap includes the skin of the first web space of the foot, with extensions running onto adjacent toes as far as
their tips. Enough skin must be removed from each toe to allow it to be folded on itself to provide both lid cover
and lining. A small area of dorsal foot skin proximal to the web is included (Fig. 33.2). The flap must be taken
from the foot on
the ipsilateral side, because the web has to provide the lateral canthus and the dorsal skin must be external.
FIGURE 33.1 A,B: Patient 10 years after orbital exenteration for rhabdomyosarcoma. Socket was lined with a

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split-thickness skin graft.
FIGURE 33.2 The flap and its vascular supply (DPA, dorsalis pedis artery; FDMA, first dorsal metatarsal artery).
OPERATIVE TECHNIQUE
After marking the specific design on the first web space, a lazy S incision is made proximally over the dorsum of
the foot. The dorsal veins from the flap are identified and traced to the greater saphenous vein. Other tributaries
are ligated, and the saphenous vein is isolated to the midfoot level. The dorsalis pedis artery and its venae
comitantes are located just lateral to the extensor hallucis longus tendon. This artery is traced distally, and its
continuation as the first dorsal metatarsal artery is identified passing into the first web space flap. The artery is
freed, and all branches, including the large proximal perforating artery, are ligated. The extensor hallucis brevis
tendon is divided during this procedure. The venae comitantes are left intact, since they may be needed as a
backup venous drainage system. The deep peroneal nerve that accompanies the dorsalis pedis artery and its
extension is identified and preserved.
At the recipient site, a vertical preauricular incision is made, and the superficial temporal artery and vein and the
temporal nerve are identified. These are freed proximally and distally for a short distance, and minor branches
and tributaries are ligated. A skin incision is then made around the orbital margin at the junction of normal skin
and the cavity lining. A strip of skin graft or conjunctiva measuring at least 1.5 cm in width is removed
circumferentially from just within the bony rim to create a recipient bed for the flap. A horizontal incision is then
made connecting the lateral side of the orbital incision to the preauricular one.
If perfusion to the isolated flap is found to be adequate, the vessels are clamped and ligated and the flap
transferred. (For closure of the donor site, see Chapter 335.) The flap is sutured into place with the dorsal skin
outward and the web on the lateral side to form a lateral canthus. The skin from each toe (the great toe is
superior) is folded on itself to provide both lid cover and lining. The thicker plantar skin is sutured first to the
edge of the orbital cavity lining, and the outer rim is sutured next. End-to-end anastomoses are then carried out
between the dorsalis pedis artery and the saphenous vein and the superficial temporal artery and vein,
respectively. The deep
peroneal nerve extension is sutured to one or two branches of the temporal nerve.

FIGURE 33.3 A,B: The flap 4 months after initial surgery. A hair-bearing Wolfe graft has provided lower lid
lashes.
FIGURE 33.4 The eye prosthesis with a flesh-colored eyelid-bearing attachment along its upper rim.
FIGURE 33.5 Diagrammatic cross section through the orbit showing how the prosthesis rests between the two
parts of the flap.
The horizontal skin wound may be closed directly over the pedicle, but if there is any tension as a result of
excess fatty tissue around the distal pedicle, a temporary skin graft may be used for closure.
When the initial edema and scarring have settled down, the flap and its pedicle will have to be defatted and
trimmed. A strip of conchal cartilage may be inserted along the new lower lid for additional support. A very thin
hair-bearing Wolfe graft inserted just below the rim of the lower lid has proved useful to provide lower lid lashes
(Fig. 33.3).
The prosthesis should be designed to fit between (not behind) the newly created upper and lower eyelids. A
small flesh-colored segment that includes upper lashes is fashioned and attached to the upper rim of the eye
prosthesis (Fig. 33.4). The prosthesis should be light and should rest securely between the two lids (Fig. 33.5). A
small additional flange will hook behind either the upper or the lower lid and may obviate the use of glue as a
means of fixation. The prosthesis should be easy to remove and replace in order to allow adequate cleansing of
the orbital cavity.

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CLINICAL RESULTS
The junction between the flesh-colored upper segment of the prosthesis and the upper lid flap provides a
very pleasing tarsal fold (Fig. 33.6).
SUMMARY
A free first web space flap can be effectively used to reconstruct upper and lower eyelids after complete
orbital exenteration.
FIGURE 33.6 A,B: Final result with prosthesis in place.
References
1. Carraway JH, Horton CE, Adamson JF, Mladick RA. Reconstruction after extended orbital exenteration. In:
Tessier P, Callahan A, Mustardé J, Salyer KE, eds., Symposium on plastic surgery in the orbital region, vol.
12. St. Louis: Mosby, 1976.
2. Meyer R. Eyelid reconstruction following enucleation and exenteration. In: Hueston JT, ed., Transactions
of the Fifth International Congress of Plastic and Reconstructive Surgery. Melbourne: Butterworth,
1971;991-1000.
3. May JW, Chait LA, Cohen BE, O'Brien BMcC. Free neurovascular flap from the foot in hand
reconstruction. J Hand Surg 1977;2:387.
4. Morrison WA, O'Brien BMcC, Hamilton RB. Neurovascular free foot flaps in reconstruction of the mutilated
hand. Clin Plast Surg 1978;5:265.

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Chapter 34
Dorsalis Pedis Free Flap for Eye Socket Reconstruction
B. GUYURON
H. P. LABANDTER
Contracted or missing eye sockets, especially in an irradiated orbit, represent a major reconstructive task for the
orbital surgeon. Failure of simple eye socket reconstruction requires complex procedures. Most grafts are
doomed to failure, and local flaps may leave undesirable donor-site scars. Distant flaps require many stages and
leave visible scars, and the patient is placed in an uncomfortable position for 2 or 3 weeks. In selected patients,
we have transferred the dorsalis pedis flap to reconstruct the missing or contracted eye socket.
INDICATIONS
This procedure should be used only if simpler techniques of eye socket reconstruction fail. The procedure
of choice for eye socket reconstruction is the application of a full-thickness skin graft. If this fails, the next
choice is a postauricular fasciocutaneous flap (see Chapter 30) or a secondary axial-pattern flap (1). If the
clinical examination indicates a diminished or absent superficial temporal pulse and the local condition
supports this finding, a vascularized dorsalis pedis flap can be chosen for eye socket reconstruction.
ANATOMY
For details of the anatomy of the flap (2, 3), see Chapters 316 and 548.
FLAP DESIGN AND DIMENSIONS
We use the central portion of the dorsalis pedis flap, the size of the flap depending on the size of the defect (Fig.
34.1A). Although the short and long saphenous veins can be used for the venous anastomosis, we prefer to use
one of the venae comitantes of the anterior tibial artery because of its length and ease of dissection. The flap is
designed with adequate dimensions to reconstruct the socket, as well as an additional de-epithelialized portion of
the margin of this flap which is used to correct the periorbital deficit.
OPERATIVE TECHNIQUE
Donor Site
Flap dissection is similar to what is described in Chapters 316 and 548. We expose the anterior tibial vessels
proximally, and the flap is dissected from proximal to distal and from medial to lateral, keeping the main vessels
attached to the overlying skin.
Recipient Site
If the superficial temporal vessels are absent or unsuitable, which is usually the indication for this procedure in
preference to a fasciocutaneous flap, the facial artery and external jugular vein are dissected free through a
small transverse cervical incision, and a subcutaneous tunnel is created to connect this area to the preauricular
incision.

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FIGURE 34.1 A: Design of the dorsalis pedis flap on the dorsum of the foot. B: The dorsalis pedis flap in
position, with vascular anastomoses and extension of the de-epithelialized portion over the supraorbital and
infraorbital rim, for augmentation of this area. C: Sagittal view of the orbit with dorsalis pedis flap in position
covering the posterior wall of the orbit and the superior and inferior orbital rim, and full-thickness skin graft lining
the posterior aspects of the eyelids.
If the superficial temporal vessels are still available, one team exposes them through a preauricular incision. The
vein is usually found anterior to the artery. However, as the vein nears the parotid gland, it is closer to the
superficial temporal artery. At this point, the lumen sizes of both vein and artery are most closely matched,
although exposure is not ideal. The vessels are isolated carefully.
A subcutaneous tunnel is then created directly from the upper pole of the parotid gland to the lateral orbital area,
preserving the temporal branch of the facial nerve. The upper and lower eyelids are then separated from the
orbit, and an attempt is made to keep the eyelids as thin as possible. Meticulous hemostasis is critical to avoid a
collection of blood under the flap.
The flap is then placed in position (Fig. 34.1B), and an adequate amount of full-thickness skin graft is harvested
from the portion of the flap that is to be de-epithelialized and is used to augment the periorbital area. The graft is
used to line the posterior aspect of each eyelid to create a sulcus. The flap is not folded under the eyelid
because of its thickness. The full-thickness skin graft is sutured to the palpebral margin or to the remnant of the
palpebral conjunctiva on one side and to the junction of the de-epithelialized and epithelial portions of the flap on
the other side (Fig. 34.1C).
A few darts along the junction of the full-thickness skin graft with the flap are advisable in order to avoid circular
contracture. Through-and-through 4-0 Prolene sutures on a Keith needle are used to anchor the sulcus to the
skin of the supraorbital and infraorbital regions. These stitches are then tied over bolsters, and the cavity is
packed (Fig. 34.2).
CLINICAL RESULTS
Along with the usual complications associated with free flaps and the dorsalis pedis donor site, injury to the
temporal branch of the facial nerve may occur.

FIGURE 34.2 A: A 17-year-old-girl who underwent enucleation of the eye and radiation to the left orbit 12
years previously. Two previous skin grafts failed to reconstruct an adequate eye socket. She also had a
persistent infection requiring removal of the silicone implant used to augment the left orbit. A free-
vascularized dorsalis pedis flap and full-thickness skin graft were used to rebuild the eye socket. B:
Although a functional eye socket was reconstructed in one stage, this flap did not provide adequate tissue
to augment the periorbital region because of the significant bony and soft-tissue deficit. The patient
underwent a second operation to reconstruct the left supraorbital rim and augment the orbital content with
rib cartilage grafts.
SUMMARY
Achievement of a functional eye socket in a single-stage operation is the main advantage of this procedure.
This operation provides an adequate amount of healthy skin with excellent blood supply and little or no
chance of contraction. The thinness of the flap is a desirable advantage. Two to three weeks later, a
temporary prosthesis can be placed in the sulcus.
References
1. Guyuron B, Labandter HP, Berlin AJ. Fasciocutaneous flap: secondary axial pattern flap and
microvascular free flap in socket reconstruction. Ophthalmology 1984;91:94.
2. McCraw JB, Furlow LT, Jr. The dorsalis pedis arterialized flap: a clinical study. Plast Reconstr Surg
1975;55:177.
3. Ohmori K, Harii K. Free dorsalis pedis sensory flap to the hand with microneurovascular anastomoses.
Plast Reconstr Surg 1976;58:546.

Chapter 35
Bilobed Nasal Skin Flaps
A. MATARASSO
B. STRAUCH
The bilobed nasal flap is a useful and time-honored technique for reconstructing defects of the nose and various
other regions of the body (1, 2, 3, 4). It is a transposition flap consisting of two lobes of skin and subcutaneous
tissue based on a common pedicle (5).
INDICATIONS
This flap is most commonly used for patients following removal of basal-cell cancers. Bilobed nasal flaps
are appropriate for partial-thickness losses of less than 1.5 cm of the lateral aspect of the nose, ala, and tip
area. It is feasible in situations where sufficient laxity exists in surrounding nasal tissue, to allow the excess
to be transposed for wound coverage, while permitting primary closure of the final donor site. The concept
of transferring tissue laxity from the upper to the lower nose or “robbing Peter to pay Paul,” allows losses of
tissue to be replaced in kind (6). A bilobed flap may also be used in conjunction with other flaps to
reconstruct more complex contour defects in the nasal area (7). For example, it may be used to cover a full-
thickness nasal-tip defect, where lining and support are provided by a composite graft to the underside of
the bilobed nasal flap.
ANATOMY
This flap is essentially a rotation flap divided into two transposition flaps. The bilobed flap has a random-pattern
blood supply. However, there is evidence that, when the flap is designed near the level of the inner canthus, a
portion has a direct axial blood supply (angular and supraorbital arteries) (8). The flap is composed of full-
thickness nasal skin and subcutaneous tissue. A readily apparent cleavage plane is established between the flap
and the underlying muscular elements.
FLAP DESIGN AND DIMENSIONS
Approaches to the bilobed flap have changed over time from consideration of two flaps alike in size and form to
the utilization of a smaller secondary flap, more triangular in shape, facilitating closure of the donor deformity (9).
Esser (10), the first to describe the use of bilobed rotation flaps for the repair of nasal tip defects, believed that
90° was the optimal angle between the two flaps; however, it could vary between 95° and 180° (11). The greater
the angle, the larger is the resultant dog-ear that must be adjusted. This should be considered when planning
the flap, because trimming the excess tissue can compromise the vascular pedicle.
Flap design and planning takes place from the defect backward to the donor site. An often stated good rule is to
measure twice and cut once. When the defect is created, the appropriate flaps are designed for resurfacing. A
useful technique involves drawing a perpendicular line through the defect and connecting the ends to form a
semicircle; two flaps are then designed within the arc. When designing the flaps, careful attention should be
given to preserve the natural borders of the nose, to prevent flap transposition from obliterating normal nasal-
cheek contours.
The primary flap used for reconstructing the defect usually lies within the mid-access at 45° or less to the defect,
and it is slightly smaller than the defect. The laxity in the surrounding skin is assessed by pinching the skin. A

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secondary flap, somewhat triangular in shape, is designed to achieve closure of the donor defect. The flaps are
raised concurrently on a common base and rotated (Fig. 35.1). After final insetting of the flap, it is frequently
necessary to adjust the base and distal edges of the flap.
OPERATIVE TECHNIQUE
In patients who do not present with an already open wound from Mohs' micrographic surgery, the tumor can be
excised under pathologic frozen-section control and the defect repaired in one stage. Flaps are not irreversibly
demarcated until negative wound margins are obtained. When dealing with recurrent or aggressive basal-cell
carcinomas, allowing the wound to granulate or using a temporary closure with a skin graft for a sufficient period
of time (e.g., 1 year) are advisable to ensure tumor eradication before a flap is fabricated. This avoids distortion
of the normal architecture in the event of recurrence.
The final defect is outlined and wound edges pared, if indicated. The two flaps are designed and raised
simultaneously, with wide undermining as necessary to allow easy rotation into position, without tension. The
primary flap closes the tumor defect and the secondary flap is used to close the donor site. At this time, final
tailoring and backcuts are judiciously performed, and the flap inset. The wounds are closed in a single layer with
5-0 nylon suture, and the secondary donor site is closed by direct advancement (Fig. 35.2).
CLINICAL RESULTS
Flaps should be designed with a sufficient length-to-width ratio, the tip handled gently, and closure
performed with minimal tension. Tension should be avoided, as it often affects the most distal aspect of the
flap, which is already in the most precarious blood-supply situation. If flap ischemia occurs, it should be
promptly recognized and treated. If tension is a
factor, sutures can be removed; if fluid collection is the etiology, it should be evacuated. Other methods to
treat venous occlusion (e.g., leeches) or arterial compromise (e.g., steroids, nifedipine, etc.) can be
considered.
FIGURE 35.1 Operative steps in closure of a nasal defect with the bilobed flap. A: Design for rotation in a
semicircle; commonly, each flap is capable of up to 90° rotation, as indicated. B: Flaps are widely elevated
to and beyond their bases, and transposed; the secondary defect is smaller than the primary, and is closed
directly. C: Insetting, final tailoring, and backcutting. D: Final results.

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As with all reconstructive cases, patients should have been previously counseled about the aesthetic
limitations, since many expect to achieve the same appearance they had prior to extirpation. The flap also
requires additional incisions that leave permanent scars in adjacent tissues.
As with all circular flaps, “pin cushioning” is a potential disadvantage of this technique. During surgery, flaps
can be thinned to the extent that the subdermal plexus is maintained. Flaps that do swell should be digitally
massaged after initial healing. Ultimately, they can require corticosteroid injections, secondary revisions, or
ancillary techniques.
SUMMARY
The bilobed nasal flap is a versatile flap that is useful for the repair of defects of the lateral nose, ala, and
nasal-tip area. It is a single-staged procedure that takes advantage of the laxity in the surrounding skin of
the upper nose, thereby providing a close color and texture match for resurfacing of nasal defects.
FIGURE 35.2 A,B: Flap design, transposition, and insetting.
References
1. Elliot RA. Rotation flaps of the nose. Plast Reconstr Surg 1969;44:147.
2. Converse JM. Reconstructive plastic surgery, 2nd ed. Philadelphia: Saunders, 1977;439.
3. McGregor JC, Soutar DS. A critical assessment of the bilobed flap. Br J Plast Surg 1981;8:587.
4. Bennett JE. Reconstruction of the nose: reconstruction of lateral nasal defects. Clin Plast Surg
1981;8:587.
5. Grabb WC, Smith JW, eds., Plastic surgery, 3rd ed. Boston: Little, Brown, 1979;49-50.
6. Millard DR, Gillies H, eds., The principles and art of plastic surgery. Boston: Little, Brown, 1957;52.

7. Jackson IT. Local flaps in head and neck reconstruction. St. Louis: Mosby, 1985;109-117.
8. Marchac D, Toth B. The axial frontonasal flap revisited. Plast Reconstr Surg 1985;76:686.
9. Dean RK, Kelleher JC, Sullivan JG, Barbak GJ. Bilobed flaps and skin flaps. In: Grabb WC, Smith JW,
eds., Plastic surgery, 3rd ed. Boston: Little, Brown, 1979;289-296.
10. Esser JFS. Gestielte locale nasonplastik mit zweizipfligem lappen: dekung des sekundaren detekes vom
ersten zipfel durch den zweiten. Dtsch Z Chir 1918;385:143.
11. Zimany A. The bilobed flap. Plast Reconstr Surg 1953;11:424.

Chapter 36
V-Y Flap Reconstruction for Nasal Alae Defects
S. L. EISENBAUM
M. P. BARNETT
EDITORIAL COMMENT
This is an attractive idea, in that it replaces skin similar to what has been lost. However, this flap has the
limitations of just about every V-Y type of advancement flap in that mobility is limited, depending on the
looseness of the skin that is being mobilized.
Sliding, subcutaneous V-Y advancement flaps for the reconstruction of nasal defects have been gaining in
popularity, especially in nasal dorsum reconstruction (1, 2, 3, 4) and, with certain precautions (see below), in
lateral nostril reconstruction. The flaps have been used for small defects of the ala nasi that do not involve the
rim.
INDICATIONS
The advantages of having like tissue in the same operative field, with an excellent blood supply, make the
V-Y flap a good choice for nasal reconstruction. It can also be used in reconstructions of the ala nasi, for
defects generally limited to less than 1.5 cm in diameter and not involving the rim. V-Y flap reconstructions
for ala defects due to basal cell carcinoma excision have been used in an outpatient setting in a small series
of patients (5).
ANATOMY
The flap described is based totally on subcutaneous connections and depends on the blood supply in this tissue
for its survival. The amount of advancement is limited mainly by the vertical depth of subcutaneous tissue
between the skin and the underlying bone or cartilage and, to a lesser extent, on the looseness of the tissue
distal to the defect. This distal tissue “back-slides” into the defect as the advancement flap pedicle applies a
force in the direction whence it came (6). The skin of the nostril is relatively unyielding, and therefore most of the
mobility rests in the flap itself.
FLAP DESIGN AND DIMENSIONS
In areas on the lateral surfaces of the nose where the subcutaneous tissue is relatively thick, large
subcutaneously based flaps can be developed and advanced with excellent results. Because of the excellent
blood supply of the nose, undermining of these flaps can be performed to a significant extent, without injuring or
compromising the flap. Most of these flaps in the lateral nose and medial face are, in actuality,
musculocutaneous flaps fed by vessels from small underlying facial muscles (6).
The closer to the alar margin one approaches, the thinner and more densely adherent the subcutaneous tissue
becomes. If an attempt is made to cut down to the surface of the cartilage along the rim, the blood supply
becomes compromised because, essentially, no blood comes through the cartilage. The thin subcutaneous
pedicle of such flaps transposed along the alar margin provides a force that may lead to notching at the alar rim

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(6).
FIGURE 36.1 A 75-year-old woman with a basal cell carcinoma of the right nostril and a 1.6 × 1.3 cm defect. A:
Preoperative lesion. B: Intraoperative defect. C: Immediately postoperative. D: Results 3 months
postoperatively. (From Eisenbaum, Barnett, ref. 5, with permission.)
OPERATIVE TECHNIQUE
In a series of nine patients with basal cell carcinoma, the procedure was done under local anesthesia in an
outpatient setting. The area of lesion excision and the flap are marked preoperatively. After excision of the lesion,
the specimen is tagged with a suture for pathologic orientation and usually sent for frozen section. Once all
margins are known to be clear, the V-Y flap is dissected out and moved inferiorly on a subcutaneous pedicle to
repair the defect; 5-0 and 6-0 interrupted nylon sutures are used. The closer the resected margin is to the alar
rim, the greater is the tendency for retraction of the nostril margin; in particular, peaking and notching of the alar
rim should be avoided (5) (Figs. 36.1 and 36.2).
CLINICAL RESULTS
This flap has limitations, particularly in instances involving the inferior margins of the nose near the nares.
Some notching along the alar rim may occur and, in younger individuals, would probably be severe. When