Grabb’s Encyclopedia of Flaps Head and Neck

3. Hardin JC, Jr. Alar rim reconstruction by a dorsal nasal flap. Plast Reconst Surg 1980;66:293.
4. Strauch B, Fox M. V-Y bipedicle flap for resurfacing the nasal supratip region. Plast Reconstr Surg
1989;83:899.
5. Eisenbaum SL, Barnett MP. V-Y flap reconstruction for nostril defects. Ann Plast Surg 1991;26:488.
6. Argenta LC. Invited comment. Ann Plast Surg 1991;26:493.
7. Hauben DJ, Sagi A. A simple method for alar rim reconstruction. Plast Reconstr Surg 1987;80:839.
8. Jackson I. Nose reconstruction. In: Berger K, ed., Local flaps in head and neck reconstruction. St. Louis:
Mosby, 1985;87-188.
9. Zook EG, Beck AL, Russell RC, et al. V-Y advancement flap for facial defects. Plast Reconstr Surg
1980;65:786.
10. Rieger RA. A local flap for repair of the nasal tip. Plast Reconstr Surg 1967;49:147.
11. Marchac D. Lambeau de rotation fronto-nasal. Ann Chir Plast Esthet 1970;15:48.

Chapter 37
Caterpillar Nasal Skin Flap for Nasal Tip Reconstruction
T. D. CRONIN
EDITORIAL COMMENT
This is a two-stage operation to restore the projection of the tip of the nose. The advanced flap is bunched
up just above the scar, and in a second procedure, the extra skin is brought down to resurface the scar. It is
not clear whether or not this procedure is applicable to freshly excised wounds. The tip of the nose also can
be resurfaced with a local “banner” flap, and projection of the tip can be obtained with a cartilage graft, if
necessary.
Small losses of the nasal tip may be repaired by a caterpillar flap, which consists of a V-Y advancement as the
first stage (1).
INDICATIONS
The caterpillar flap is suitable for repairing small losses of the nasal tip. If nasal lining is required, this
method would probably not be adequate unless small flaps could be turned in from the margins for lining.
Thick, sebaceous, or excessively scarred nasal skin might be too thick or stiff to fold properly.
ANATOMY
The blood supply to this flap follows a random pattern. Blood supply of the skin of the nose is very robust and
survives on narrow and even scarred pedicles.
OPERATIVE TECHNIQUE
First Stage
A triangular flap is elevated, taking care to carry the apex no higher than or only slightly higher than the inner
canthi to avoid difficulties in closure owing to fixation of the skin at the latter points. The flap is advanced
downward and folded onto itself. A shift of 1 to 1.5 cm can be accomplished readily.
The skin edges are widely undermined, and the upper end of the wound is closed for a distance equal to the
advancement required. In closing the remainder of the wound, it is wise to draw the skin edges medially from one
skin edge to the other by the use of buried sutures to prevent tension from side to side on the flap. Furthermore,
so as not to lose any of the length of the flap, it should be kept completely extended while it is being sutured. In
this way, a maximum amount of tissue is folded onto itself near the tip.
Second Stage
Three to 6 weeks later, the skin is unfolded and brought down to form the new tip—its rounded shape forms an
admirable tip. If an increase in the prominence of the new tip is desired, a small piece of septal or ear cartilage
can be inserted (Figs. 37.1 and 37.2).

SUMMARY
A two-stage caterpillar flap can be used to reconstruct small defects of the nasal tip.
FIGURE 37.1 A: Small loss of nasal tip. (Continued)
FIGURE 37.1 Continued. B: The flap includes the full thickness of the skin down to the loose areolar tissue
and extends down as near to the defect as possible, while still retaining a blood supply. At the canthal level
the flap should not be too wide. C: Three to 6 weeks later, the distal end of the flap is unfolded to form the
new nasal tip. (From Cronin, ref. 1, with permission.)

FIGURE 37.2 A,B: Small loss of nasal tip. C,D: Appearance after elevation, advancement, and folding of
the flap. E,F: Appearance 27 days after the second stage. Avoidance of notching at the canthal level on
profile is avoided by not making the flap too wide at that level. (From Cronin, ref. 1, with permission.)
Reference
1. Cronin TD. A new method of nasal tip reconstruction utilizing a local caterpillar flap. Br J Plast Surg
1951;4:180.

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Chapter 38
V-Y Bipedicle Flap for Resurfacing The Nasal Supratip Region
B. STRAUCH
M. FOX
For resurfacing the nasal supratip region, use of the V-Y bipedicle flap allows the concealment of the lower
incisions in the normal alar creases and of the upper incisions in the glabellar folds (1).
INDICATIONS
The supratip area of the nose lies between the tip area and the nasal dorsum, overlying the septal angle of
the cartilaginous septum. Supratip nasal skin has a distinctive texture, contour, and color. Techniques used
for resurfacing this area include skin and composite grafts and local and distant flaps (1, 2, 3, 4, 5, 6, 7). If
the incisional lines are so placed as to be hidden in the natural creases, a local flap would appear to be the
most satisfactory choice, since it provides for restoration of both normal contour and skin color.
FIGURE 38.1 A: Outline of supratip excision, with high V planned, beginning in the glabellar area. B:
Bipedicle flap mobilized and shifted distally. Distal tip is elevated to meet the leading edge of the flap. C:
Closure of defects. (From Strauch, Fox, ref. 1, with permission.)
FLAP DESIGN AND OPERATIVE TECHNIQUE
The lesion in the supratip area is marked for appropriate excision. Two lateral triangular areas are then drawn to
the nasolabial folds, defining an elliptical defect, the lower borders of which conform to the upper borders of the
alar crease. A V is then planned, starting high in the glabellar area, coming down the side of the nose, and
extending out on the cheek in the border between the cheek and the eyelid skin (Fig. 38.1A).
The lesion and the triangular areas are then excised, and the upper part of the flap is incised. The nasal skin is
completely undermined over the entire surface of the nose, extending to the nasolabial fold laterally on each
side. The distal tip skin is undermined slightly to provide easier closure.

FIGURE 38.2 A 50-year-old man with basal cell carcinoma of the supratip area. A: Preoperative frontal view. B:
Preoperative profile. C: Outline of incisions. D: Intraoperative closure. E: Postoperative frontal view. F:
Postoperative profile. G: Close-up. (From Strauch, Fox, ref. 1, with permission.)
The bipedicle flap can then be advanced distally for up to 1.0 cm, and the point of closure of the Y can be
determined. The tip of the nose is brought up to meet the leading edge of the flap (Fig. 38.1B). The defects are
closed (Fig. 38.1C). Resection of a segment of the lower lateral cartilages may facilitate this maneuver. A
surgical defect of up to 1.5 cm may be corrected in this manner (Figs. 38.2 and 38.3).
CLINICAL RESULTS
Resurfacing the nasal supratip area with a local flap yields attractive results, since it provides tissue of
normal color, contour, and texture in a single stage. Skin grafts may result in a contour defect, as well as
pigmentary changes. Although a composite graft may minimize contour defects, pigmentary changes may
still occur. Nasolabial flaps do not provide sufficient length for cross-midline coverage and tend to interrupt
the normal flow of the nasolabial fold.
Bilobed flaps (2, 3) provide coverage for the supratip area; however, the multiple incisions necessary on the
leading surface of the nose, as well as the trapdoor tendency of small flaps in this area, make this
procedure less attractive. The unipedicle flap (4, 5, 6) imposes an additional scar along the length of the

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nasolabial area. In addition, fullness results in the area of pedicle rotation. An advantage of the unipedicle
flap is that it can resurface the area distal to the supratip.
The V-Y bipedicle flap allows for easy closure in the glabellar area and a suture line that is well hidden in
the alar creases (1). It provides tissue of optimal match for color, texture, and
contour. The bipedicle attachment also provides for an extremely hardy circulation (7). The flap advances
distally for 1.0 cm, and the mobility of the nasal tip provides an additional 0.5 cm of advancement. The
elevated tip descends to a more normal location in the postoperative period. This technique should not be
used for surgically created defects greater than 1.5 cm in diameter.
FIGURE 38.3 A 72-year-old man with basal cell carcinoma of the supratip area. A: Preoperative frontal
view. B: Intraoperative drawing. C: Late postoperative view. (From Strauch, Fox, ref. 1, with permission.)
SUMMARY
A procedure for the coverage of surgically created supratip defects up to 1.5 cm in diameter is described
using a V-Y bipedicle flap of nasal skin.
References
1. Strauch B, Fox M. V-Y bipedicle flap for resurfacing the nasal supratip region. Plast Reconstr Surg
1989;83:899.
2. Zimany A. The bilobed flap. Plast Reconstr Surg 1953;11:423.
3. Elliot RA Jr. Rotation flaps of the nose. Plast Reconstr Surg 1969;44:147.
4. McGregor I. Fundamental techniques of plastic surgery. Edinburgh: E&S Livingston, 1965;171.
5. Rieger R. A local flap for repair of the nasal tip. Plast Reconstr Surg 1967;40:147.
6. Marchac D, Toth B. The axial frontonasal flap revisited. Plast Reconstr Surg 1985;76:686.

7. Furnas DW, Furnas H. Angular artery flap for total reconstruction of the lower eyelid. Ann Plast Surg
1983;10:322.

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Chapter 39
Banner-Shaped Nasal Skin Flap
J. K. MASSON
B. C. MENDELSON
EDITORIAL COMMENT
This flap should probably be considered as a first choice for many smaller nasal defects.
Most defects on the lower two-thirds of the nose are best closed with what Elliott (1) named a “banner flap,”
presumably because the triangular shape of the flap resembles a banner or pennant. Although described by
Elliott as a rotation flap, it is essentially the larger of two unequal flaps transposed as a type of Z-plasty (2).
INDICATIONS
The main indications for the frequent use of the banner flap are its versatility and safety, which are more
recognized with increased use of the flap. Frequently, defects that are 1.5 to 2 cm in diameter have been
closed, and on several occasions,
defects as large as 2.5 cm in diameter have been managed. In some circumstances, the flap has been
taken from below the defect or extended onto the cheek or has been converted into a bilobed flap.
Skin grafts may have a good color match, but they leave an obvious depression. Nasolabial flaps provide
an excellent color match, but the amount of subcutaneous fat and the possibility of a second stage to divide
the pedicle limit their usefulness. Even then, one-fourth of the patients have required a separate defatting
procedure to improve the appearance of the flap.
We believe that the larger flaps described by Rieger (3) and Lipshutz and Penrod (4) have no inherent
advantage over banner flaps. In fact, they share the risks involved, in that they require more extensive
mobilization of the skin. Situations requiring more complicated flaps, such as island pedicle flaps from the
forehead or subcutaneous pedicle flaps from the forehead or nasolabial region, are infrequent.
ANATOMY
The terminations of the external maxillary artery form the main arterial supply and allow the successful use of
many kinds of random flaps. The veins of this region empty into the anterior facial vein and also communicate
through the ophthalmic vein with the cavernous sinus. The lymphatic vessels drain to the submaxillary and deep
cervical lymph channels.

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FIGURE 39.1 Principles of the banner flap procedure. A: Triangular flap is outlined by points a, b, and c. B:
Larger flap x and smaller flap y. Each may be transposed as a modified Z-plasty. C: Flap y is inset, and tip of flap
x is trimmed to fit the residual defect. D: The resultant dog-ear at point a, if excessive, may be reduced by a
triangular excision (leaving the base untouched). (From Masson and Mendelson, ref. 2, with permission.)
FLAP DESIGN AND DIMENSIONS
Time spent on initial outline of the best flap design is most worthwhile. The flap is outlined with a marking pen at
a tangent to the edge of the defect, merging at point a (Fig. 39.1A and B). Point b is marked well out laterally
and, if convenient, is placed in the alar crease, where the scar will tend to be camouflaged. However, for other
than small defects, point b must be placed higher than the alar crease to minimize subsequent elevation of the
nostril rim (Fig. 39.2A).
The length ab is significantly longer than the diameter of the defect, since the flap will be long and narrow,
allowing easier closure of the secondary defect. The tip of the banner flap x will be excised later. Point c is
placed above the defect, but not necessarily out to the lateral extent of the defect; this point can be extended
later, if needed, to allow a better fit of the base of the flap into the defect.

FIGURE 39.2 Operative steps in the banner flap procedure. A: For a larger defect, point b is placed higher than
the alar crease, to reduce elevation of the nostril rim. B: Elevation and mobilization of both flaps x and y. C:
Elevation of the nasal tip advances flap y upward and closes the donor area. This is held with a few buried
catgut sutures. D: Flap x is then tailored to fit the operative defect, and the skin incision is closed with skin
sutures.
The base of the flap ac is made narrower than the diameter of the defect, because during closure the defect can
be narrowed in its transverse diameter to fit the slightly narrower flap.
OPERATIVE TECHNIQUE
The flap is outlined and elevated (Fig. 39.2B) with wide undermining of the nasal skin using blunt dissection on
the cartilaginous plane (especially under the base of the flap x) to allow ease of rotation. Flap y is also elevated
(Fig. 39.1C and D).
The smaller flap y is transposed toward point c (Fig. 39.1C) and set in position with two or three buried chromic
catgut sutures on side bc. Once flap y is inset, the final size and shape of the defect are apparent.
The larger flap x is inset by laying it down over the defect, and with the scalpel, the flap is trimmed across the
redundant tip, curved to the shape of the defect (Fig. 39.2C). The flap is then secured. Starting at the distal end
of the flap, 6-0 silk skin sutures are carefully placed to even out the discrepancy in length between the two sides
being sutured. No buried catgut sutures are used on the flap because they tend to cause distortion. The closure
toward point a is performed last, because there is usually the need to excise a small triangle in this area (Fig.
39.1D).
CLINICAL RESULTS
Fortunately, older patients who are the ones most likely to have epitheliomas are also the most favorable
candidates for a local flap, since aging skin leads to laxity with redundance to the point of drooping of the

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nasal tip.
With the transposition of a banner flap to close a defect on the external nose, there is some resultant
shortening as the donor area of the flap is closed. In such a situation, the shortening provides some definite
cosmetic improvement and also often results in functional improvement by enhancing the airway.
Asymmetrical elevation of the alar rim tends to occur when the banner flap is taken primarily from one side
of the nose. This can be minimized by taking the flap from across the bridge of the nose, so that the donor
defect involves both sides of the nose. With closure, therefore, a more symmetrical shortening is produced
than if the flap were taken primarily from one side of the nose (Fig. 39.3). Some asymmetrical elevation of
the nostril rim can be tolerated because, as with the incision, the defect will all but disappear within a period
of months (Fig. 39.4).
The safety of the banner flap was demonstrated several years ago in our first report on 100 such flaps. Of
this group, only three were not satisfactory. There was partial necrosis
in one, which healed by secondary intention; another flap dehisced after suture removal, requiring
resuturing; and a third flap left unsatisfactory scars, which required a surgical revision at a later date. Since
that report in 1977, we have continued to use and to be satisfied with the results that this flap offers in
repairing many surgical defects of the external nose (Fig. 39.5).
FIGURE 39.3 A: Typical defect. B: One year postoperatively, minimal nostril elevation. (From Masson and
Mendelson, ref. 2, with permission.)
FIGURE 39.4 A: Lateral alar defect could have been covered with a nasolabial flap. B: Banner flap 6
months postoperatively. No deformity, because of excellent match of color and texture, with preservation of
contour. (From Masson, Mendelson, ref. 2, with permission.)

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FIGURE 39.5 A: Very large defect. B: Fifth day after operation. Moderate alar rim distortion could have
been reduced with bilobed flap; note how the defect has narrowed transversely to a vertical ellipse. C:
Result 3 years after surgery. Symmetry improved. (From Masson, Mendelson, ref. 2, with permission.)
SUMMARY
Wide experience with the banner flap for closure of postoperative defects of the nasal dorsum shows that it
is not only a predictably safe and versatile procedure, but also that its use permits a superior cosmetic
result.
References
1. Elliott RA, Jr. Rotation flaps of the nose. Plast Reconstr Surg 1969;44:147.
2. Masson JK, Mendelson BC. The banner flap. Am J Surg 1977;134:419.
3. Rieger RA. A local flap for repair of the nasal tip. Plast Reconstr Surg 1967;40:147.
4. Lipshutz H, Penrod DS. Use of complete transverse nasal flap in repair of small defects of the nose. Plast
Reconstr Surg 1972;49:629.

Chapter 40
Nasolabial and Cheek Skin Flaps
R. R. CAMERON
EDITORIAL COMMENT
The versatility and usefulness of the nasolabial flap are well known. If it is superiorly based for resurfacing
of the nose, it should be based on the angular vessels and swung like a pendulum, rather than as a rotation
flap, to avoid an excessive dog-ear. When used to resurface the tip of the nose, it is likely to result in a
“biscuit-like” deformity that is best handled by excising the top surface of the flap tangentially and then
covering it with a full-thickness skin graft. The nasal and cheek junction, which is an important landmark, is
lost after use of this nasolabial flap.
Nasolabial and cheek skin flaps can be ideal sources for partial nasal reconstruction (1, 2, 3, 4, 5, 6, 7, 8, 9, 10,
11, 12, 13, 14, 15, 16, 17, 18, 19). Exact duplication is impossible because of the unique features of the skin
covering the nose: thin, resilient, and clear cephalad; thicker, less mobile, and sometimes with prominent pores
and blood vessels caudally. The cheeks and forehead are the best color matches, and their proximity simplifies
transfer. Flaps from both these areas can be developed in superficial planes so that bulk is diminished.
There is an area of relative redundancy that extends from the inner canthus of the eye to the inferior margin of
the mandible, especially in older patients. Most smaller flaps are drawn from the outpouching of redundant tissue
from the ala of the nose to the crura of the mouth. This area is generally free of hair growth, except for the lower
cheek in males.
Medially, superiorly, and laterally based flaps are best used for reconstruction of the nose, while inferiorly based
flaps lend themselves to transfer to the upper lip and nasal floor.
INDICATIONS
Flap tissue is necessary for coverage when there is a full-thickness defect of the nose or when bone or
cartilage are exposed. Nasolabial cheek tissue can be used for coverage of defects of any part of the nose.
The more cephalad portion, however, is usually best covered by forehead tissue.
Coverage of the lateral wall is often possible by direct advancement with wide undermining (Fig. 40.6) or by
rotation of a subcutaneous pedicle flap from the nasolabial fold (see Chapter 44).
The alae of the nose also can be reconstructed using nasolabial flaps. Local turnover flaps or the addition
of cartilage within the flap may be necessary for support. Narrow flaps may be used to reconstruct losses in
the alar rim or to correct retraction of the rim, such as is seen with severe facial burns. The rim may be
released and restored to its normal position, and the defect so created can be filled with a small nasolabial
flap (Fig. 40.4).
Reconstruction of the columella presents a problem because of its small size and the difficulty of duplicating
the gentle flare at its junction with the upper lip. Passage of a superiorly based flap through an incision in
the alar crease allows placement of the flap about the columella and also provides for septal and nasal floor
reconstruction (Fig. 40.3).
Nasolabial flaps can be turned over and used for lining. Coverage can be achieved using a variety of

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methods (Fig. 40.2).
FIGURE 40.1 A: Superiorly based nasolabial flap indicating point of rotation. B: Inferiorly based nasolabial
flap indicating point of rotation. C: Large inferiorly based nasolabial cheek flap.
FIGURE 40.2 A,B: Wide excision of a recurrent basal cell carcinoma. C: Lining of a full-thickness defect of
the nasal dorsum and side wall is provided by an inverted, medially based nasolabial flap. D: Coverage is
obtained from the opposite side. E: Postoperative result. (From Cameron et al., ref. 11, with permission.)

FIGURE 40.3 A,B: Resection of a large basal cell carcinoma requiring reconstruction of the columella,
upper lip, and nasal floor using bilateral nasolabial flaps. C: The left nasolabial flap was used to resurface
the lip and nostril floors. D: The right nasolabial flap was brought through an incision in the top of the right
ala and used to reconstruct the columella. Later, the pedicle was severed and returned. E: Postoperative
result. (From Cameron et al., ref. 11, with permission.)
ANATOMY
Blood supply to the nasolabial and cheek skin is from the angular artery (a branch of the anterior facial artery),
the infraorbital artery, the transverse facial artery, and the infratrochlear artery (20).
Nasolabial cheek flaps are random flaps, since no attempt is usually made to include any specific arterial supply.
Because of the rich vascularity and free anastomoses of arterial supply and venous drainage, superior, medial,
lateral, and inferior pedicles are possible. Subcutaneous pedicles are, however, more reliable if based laterally or
inferiorly. This is so because the development of the subcutaneous pedicle interrupts the rich subdermal network
of vessels. Development of a nasolabial flap on an arteriovenous pedicle using the facial artery and vein has
been described.
While the sensory supply of these flaps is rarely critical, these flaps are often fortuitously included with superior
or lateral pedicles because of the orientation and arborization of the infraorbital nerve.
FLAP DESIGN AND DIMENSIONS
Flap size is limited by the redundancy of tissue and the ability to close the donor site primarily without deformity.

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Within these parameters, size is determined by the need for lining of the nose or for inclusion of bone, cartilage,
or alloplastic support. If such requirements are present, the flap may need to be doubled on itself or lined by a
second flap or skin graft.
Superiorly and medially based flaps are limited in width. Rarely, as much as 5 cm has been used. The flap may
be up to 10 to 12 cm in length, as long as appropriate delay procedures are used. Shorter flaps rarely require a
delay, unless there is questionable vascularity of the tissues. Rotation of superiorly based flaps usually occurs
about a point just medial to the superior end of the lateral incision (point B in Fig. 40.1A).
Inferiorly and laterally based flaps are more limited in available length. Tissue based laterally and advanced onto
the nose is most restricted by the available redundancy between the inner canthus of the eye and the nasolabial
fold. Much
more tissue is available, however, if rotation-advancement techniques are used with cheek tissues, much as
Mustardé has demonstrated for lower eyelid reconstruction (21). The point of rotation for these flaps will be just
medial to the inferior extent of the lateral incision (point B in Fig. 40.1B).
FIGURE 40.4 A: Resurfacing of the lateral nose in a patient scarred by aggressive dermabrasion. B: The ala is
advanced and the defect is lined with an inverted flap. C: Superiorly based nasolabial flap used for cover. D:
Postoperative result awaiting further resolution and possible revision.

FIGURE 40.5 Resurfacing of the nasal dorsum with bilateral nasolabial cheek flaps. (From Cameron et al., ref.
11, with permission.)
FIGURE 40.6 A: Patient with radiation change and secondary neoplastic lesions. B,C: Resurfacing of the lateral
nose and upper lip with rotation-advancement nasolabial cheek flap. D: Postoperative result.
OPERATIVE TECHNIQUE
Orientation of the pedicle will be determined by the location of the defect and the requirements for rotation and/or
advancement of appropriate amounts of tissue to the defect with the least amount of torsion and tension on the
pedicle. Flap thickness is partly determined by the needs of the defect, but it is limited by the thickness of the
donor tissues. In most cases, the requirements are for a thin flap, and elevation is made in the subdermal plane.
In all cases, elevation should protect the muscles of facial expression and the nerves that supply them.
In many instances, secondary revisions are required to obtain the best aesthetic result. The reduplication of
nasal contours is difficult at best, so some patients may be disappointed with the results. Proper initial design,
precise estimate of size, and careful insetting of the flap, combined with segmental replacement of tissue, when
practical, will frequently obviate extensive secondary revision.
CLINICAL RESULTS

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Use of nasolabial cheek tissues loses much of its advantage if significant donor deformities result. For this
reason, the mechanics of transfer must consider primary donor-site closure without irreparable secondary
deformity. If the procedure is ill-conceived, ectropion of the lower eyelid or upper lip can occur.
Placement of a donor incision in the midface is abhorrent to many reconstructive surgeons. However, the
scars resulting from transfer of this tissue can be quite acceptable if care is taken with donor-site closure.
Such scars are often preferable to the deformities sometimes seen with forehead donor sites.
Z-plasties, W-plasties, scar revisions, and replacement of bulky flaps with full-thickness grafts may all have
a place in secondary revisions (Fig. 40.6). There are particular problems in using nasolabial tissue in elderly
males with thick nasal and adjacent skin—a procedure that may result in bulky, contracted flaps (22).
SUMMARY
Nasolabial and cheek skin can be used to reconstruct the various areas of the nose. Superiorly, inferiorly,
medially, and laterally based flaps have their particular applications and limitations.
References
1. Hagerty RF, Smith W. The nasolabial cheek flap. Am Surg 1958;24:506.
2. McLaren LR. Nasolabial flap repair for alar margin defect. Br J Plast Surg 1963;16:234.
3. DaSilva G. A new method of reconstruction of the columella with a nasolabial flap. Plast Reconstr Surg
1964;34:63.
4. Pers M. Cheek flaps in partial rhinoplasty. Scand J Plast Reconstr Surg 1967;1:37.
5. Reginata LE, Belda W. Correction of scaphoid facies and restoration of nasal foundation with bilateral
nasolabial flaps. Rev Paul Med 1968;72:130.
6. Wynn SK, Wiviott W. Resurfacing the nose with bilateral cheek flaps. In: Transactions of the 4th
International Congress of Plastic and Reconstructive Surgery. Amsterdam: Excerpta Medica, 1968;590.
7. Georgiade NG, Mladick RA, Thorne FL. The nasolabial tunnel flap. Plast Reconstr Surg 1969;43:463.
8. Wesser DR, Burt GB, Jr. Nasolabial flap for losses of the nasal ala and columella. Plast Reconstr Surg
1969;44:300.
9. Climo MS. Nasolabial flap for alar defect. Plast Reconstr Surg 1969;44:303.
10. Heybrook G. Some applications of the nasolabial flap in reconstruction of the nose and lips. Br J Plast
Surg 1970;23:26.
11. Cameron RR, Latham WD, Dowling JA. Reconstructions of the nose and upper lip with nasolabial flaps.

Plast Reconstr Surg 1973;52:145.
12. Fryer MP. Subtotal nose reconstruction with a cheek flap. Plast Reconstr Surg 1974;53:436.
13. Cameron RR. Nasal reconstruction with nasolabial cheek flaps. In: Grabb WC, Myers MB, eds. Skin
flaps. Boston: Little, Brown, 1975.
14. Millard DR, Jr. Reconstructive rhinoplasty for the lower two-thirds of the nose. Plast Reconstr Surg
1976;57:722.
15. Jackson IT, Reid CD. Nasal reconstruction and lengthening with local flaps. Br J Plast Surg 1978;31:341.
16. Orticochea M. Reconstructing one-half of the nose with a combined cheek and upper lip flap. Br J Plast
Surg 1979;32:217.
17. Antia NH, Daver BM. Reconstructive surgery for nasal defects. Clin Plast Surg 1981;8:535.
18. Bennett JE. Reconstruction of lateral nasal defects. Clin Plast Surg 1981;8:587.
19. Guerrerosantos J, Dicksheet S. Nasolabial flap with simultaneous cartilage graft in nasal alar
reconstruction. Clin Plast Surg 1981;8:599.
20. Corso PF. Variations of the arterial, venous and capillary circulation of the soft tissues of the head by
decades as demonstrated by the methyl methacrylate injection technique, and their application to
construction of flaps and pedicles. Plast Reconstr Surg 1961;27:180.
21. Mustardé JC. Repair and reconstruction in the orbital region, 2d Ed. Edinburgh: Churchill-Livingstone,
1980.
22. Walkinshaw MD, Caffee HH. The nasolabial flap: a problem and its correction. Plast Reconstr Surg
1982;69:30.

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Chapter 41
Zygomatic Flap for Reconstruction of The Lip and Nose
A. GARDETTO
C. PAPP
EDITORIAL COMMENT
The editors have no experience with this relatively new flap. Nonetheless, the good anatomic studies would
make it an appropriate flap for reconstruction of soft-tissue defects of the upper lip and the nose.
Reconstruction of soft-tissue defects of the upper lip and the nose, especially of the tip and the columella, is still
one of the most difficult tasks for a plastic surgeon. Numerous possibilities, such as a composite graft,
transposition flaps, and local flaps, have been described in the literature.
INDICATIONS
Although full-thickness skin grafts or transposition flaps may satisfy the requirements of the reconstruction,
their aesthetic outcome is often not quite satisfactory. Color match and contour irregularity may be problems
in grafts; also, conventional transposition flaps, such as the nasolabial flap, often retain a “bulky”
appearance, even many years later (1). However, in many cases, a primary reconstruction with a final good
result is not always possible because of the limited advancement. For these reasons, we consider the
zygomatic flap as a new and promising approach for a one-stage procedure (2). The donor defect is quite
similar to the nasolabial flap and therefore cosmetically inconspicuous. As an island flap, the zygomatic flap
offers a big arc of rotation. Usually, there is no destruction of muscle and nerve tissue, and because of the
central vessel, the arc of rotation is essentially larger.
ANATOMY
The zygomatic flap is supplied by the cutaneous zygomatic branch, a branch of the facial artery (3). It runs
upward over the buccinator muscle and divides into two branches at the major zygomatic muscle's inferior
border. One ascends
laterally and branches out in the subcutaneous fatty tissue. The second one continues through the major
zygomatic muscle and penetrates the subcutaneous tissue above the muscle, similar to the first branch.
FLAP DESIGN AND DIMENSIONS
The zygomatic flap is an island axial pattern flap, and when properly designed, it can follow naturally existing
contour lines, thus respecting and preserving the normal facial topography and leaving the patient with minimal
surgical deformity. For the design of the flap, it is very important to mark the origin of the cutaneous zygomatic
branch. The measurements based on the auxiliary lines proposed by the authors make the dissection of the
vessel's origin relatively easy (Fig. 41.1).
The point of origin from the facial artery is defined by using the mean-distance calculation of 10 mm lateral from
the vertical line and 28 mm below the transverse line. The flap has to be designed directly over the origin of the

cutaneous zygomatic branch. The size of the flap has been demonstrated by selective injection of the cutaneous
zygomatic branch, indicating the supplied skin territory. The length of the flap is extended from 1 to 1.5 cm distal
to the vessel's origin until the transverse line, for a total length of 4 cm. However, the width of the flap is
extended strictly from the nasolabial fold, its medial border, until 2 cm toward the cheek area. The width
especially should not be designed too large, to ensure a tension-free wound closure. Because of the presented
anastomosis with other cutaneous branches from the facial artery and the infraorbital artery, the maximum
potential length reaches to 6 cm (2, 3). In this way, an enlargement of the axial skin flap is possible, and the arc
of rotation can be extended by orthograde and retrograde pedicles (Fig. 41.1). Thus, the flap can be designed to
abut the ala of the nose, and reconstruction of nasal defects can be achieved without conspicuous scars.
FIGURE 41.1 Schematic diagram depicting left hemiface. Auxiliary lines proposed by the authors: V, vertical line
through the three pressure points of the trigeminal nerve branches; T, transverse line through the most caudal
parts of the zygomatic processes of the maxilla. Topogram shows the distance of the described cutaneous
zygomatic branch origin. The right and left hemifaces are shown together, and the distances are measured in
millimeters in relation to the auxiliary vertical line and transverse line: crosses, left side; rhomboids, right side;
spot, mean distance (n = 34). The ellipsoid visualizes the radius of the potential branch origin. Right hemiface:
Arc of rotation of the zygomatic flap by orthograde (upper lip) and retrograde (nose) pedicles is shown.
OPERATIVE TECHNIQUE
After skin incision, the flap is elevated from the medial border in the subcutaneous plane, always keeping in mind
that the goal is tension-free advancement, with maximum preservation of the underlying subcutaneous pedicle.
After identification of the facial artery and the origin of the cutaneous zygomatic branch, a careful preparation of
the pedicle is necessary to allow a maximum arc of rotation.
Once selected, the skin paddle is dissected by incising down to the underlying muscle without cutting it. It is very
important to dissect the flap strictly above the fascia of the mimic musculature, to prevent injuries of the buccal
branches of the facial nerve. As soon as the island flap is circumscribed, it can be raised and carefully
transposed into the defect, exercising caution to not twist the pedicle. If the defect lies at the tip of the nose, the
flap should be transferred through a subcutaneous tunnel, and the pedicle positioned underneath the alar groove
incision. The long pedicle of this flap allows a reconstruction without bulking. The donor area is sutured primarily
in the nasolabial fold, and a drain is inserted for 24 hours (Fig. 41.2).

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SUMMARY
The zygomatic flap can follow naturally existing contour lines while retaining color match and texture. The
advantage of the nasolabial flap as a transposition flap is the long axial pedicle, which enables transposition
of the island flap at the base, allowing for adequate tissue replacement as well as its use for deep defects
without bulking. The procedure relies on the fact that the cutaneous zygomatic branch is a constant branch
of the facial artery. It is always present and its position can be easily marked preoperatively, simplifying the
surgical technical effort.
The existence of anastomosis between the zygomatic branch and cutaneous branches from the infraorbital
artery allows the extension of the arc of rotation by orthograde and retrograde pedicles. Because of this
enlargement, the axial skin island flap is a good possibility, and reconstruction of nasal tip defects can be
performed without considerable scars (Figs. 41.2 and 41.3). Therefore, it can be considered by every
plastic surgeon as an option in reconstruction of soft-tissue defects of the nasal and perinasal regions. Our
experience with the new island axial pattern flap has been good, and we can recommend this technique.
However, we must emphasize that exact anatomic knowledge, combined with careful dissection, is the basis
for successful dissection and application.
FIGURE 41.2 A: Preoperative: A 70-year-old woman with a recurrence of a basal-cell carcinoma extending
from the tip to the bridge of the nose. B: Intraoperative: The area of the wide resection of the tumor is
shown. C: Intraoperative: The elevated zygomatic flap pedicled on the cutaneous zygomatic branch and
transposed into the defect. D: Postoperative: Appearance at 6 months.

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FIGURE 41.3 A: Preoperative: A 57-year-old man with a soft-tissue defect on the tip of the nose following a
dog bite and previously unsuccessful surgery. B: Postoperative: View of an excellent result following
reconstruction with the zygomatic flap 8 months after operation.
References
1. Kalus R, Zamora S. Aesthetic considerations in facial reconstructive surgery: the V-Y flap revisited.
Aesthetic Plast Surg 1996;20:83.
2. Gardetto A, Erdinger K, Papp C. The zygomatic flap: a further possibility in reconstructing soft tissue
defects of the nose and upper lip. Plast Reconstr Surg 2004;113:485.
3. Gardetto A, Moriggl B, Maurer H, et al. Anatomical basis for a new island axial pattern flap in the perioral
region. Surg Radiol Anat 2002; 24(3-4):147.

Chapter 42
Cheek Advancement Flap for Paranasal Reconstruction
G. KRONEN
T. BENACQUISTA
B. STRAUCH
EDITORIAL COMMENT
This is an excellent and reliable flap for defects in the paranasal area. One should always remember not to
extend the flap into the nose; by doing so, the rules of the aesthetic unit will be broken, resulting in an
unacceptable outcome that will require secondary revision.
The cheek enjoys an obvious prominence in the architecture of the face. In older patients, there is an area of
relative redundancy of tissue extending from the medial canthus of the eye to the inferior border of the mandible,
providing for more available skin for the reconstructive procedures often required in this age group. With the use
of cheek advancement flaps for paranasal reconstruction, important considerations include the anatomic
complexity of the region (1, 2, 3), the avoidance of excess skin excision and resultant scarring and contracture,
and careful flap design to avoid the transfer of hair-bearing skin (2). It is also important to match flap thickness as
closely as possible to that of the original defect to achieve the most pleasing aesthetic outcome (4).
INDICATIONS
Cheek advancement flaps are useful for coverage of the paranasal region, when there is a full-thickness
defect in this area, or when bone is exposed at the nasomaxillary junction or maxilla. Split-thickness skin
grafts do not usually provide satisfactory coverage, since the contraction associated with wound healing
tends to pull the lower-eyelid margin inferiorly. Full-thickness skin grafts taken from the postauricular,
preauricular, or supraclavicular region will provide excellent texture, color match, and resilient skin;
however, they will be noticeable as patches in an otherwise unscarred face (4), when applied to defects
greater than 5 mm in depth.
ANATOMY
There is a rich vascular anastomotic network supplying the cheek skin, which is based on branches of the
external carotid artery, with a smaller contribution from the internal carotid artery. The facial artery, which
courses superomedially from the lower border of the mandible toward the modiolus near the buccal angle,
constitutes the main blood supply. Other contributions are received from the transverse facial artery (a branch of
the superficial temporal artery), the buccal and infraorbital branches of the internal maxillary artery, and the
zygomatic branch of the lacrimal artery (a branch of the ophthalmic artery).
Venous drainage of the cheek parallels the arterial system. Lymphatic drainage is achieved via the superficial
and deep parotid nodes, the buccal nodes surrounding the facial vein, and the submandibular nodes, ultimately
to empty into the cervical chain of lymph nodes (5, 6, 7, 8).
Cheek flaps are usually designed as random pattern flaps. Because of the rich anastomotic network of arterial

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supply and venous drainage, there is little concern as to their cutaneous viability, and no attempt is made to
incorporate an axial vascular supply. This allows for great freedom when planning random-pattern flaps for
reconstruction, as flaps that are based superiorly, medially, laterally, and inferiorly are all possible. However,
caution must be exercised when elevating these flaps, so that a layer of subcutaneous tissue is raised with the
flap, to preserve the subdermal vascular plexus.
FLAP DESIGN AND DIMENSIONS
The cheek advancement flap can be utilized to reconstruct defects of various sizes in the paranasal region.
Advantages of the flap are that it is very extensile because excess skin in the neck and preauricular regions can
be mobilized as necessary, to close the defect, and closure of the donor site is effected without residual
deformity (2). Flap design is therefore limited
primarily by the amount of redundant tissue present that can pose a challenging problem in younger patients
because of the reduced amount of donor tissue possible.
When designing cheek flaps, incisions should be preferably placed within lines of relaxed skin tension or in
wrinkle lines; the end results will then be a fine scar that is well camouflaged (9). The limiting factor is the cheek-
nasal junction. The flap should not be used to cover or replace nasal skin.
OPERATIVE TECHNIQUE
The excision is planned as a square or rectangle (2). From the side of the defect, two incisions are drawn—one
along the nasolabial fold medially, and another superiorly along the lower eyelid-cheek junction where the thin
skin of the lower eyelid begins to thicken. Flap dissection then proceeds in the subcutaneous plane, to preserve
the subdermal vascular plexus, extending inferiorly and laterally as far as necessary, to mobilize the flap enough
to close the paranasal defect.
As dissection proceeds inferiorly along the nasolabial fold and approaches the inferior border of the mandible
and mid-cervical region, elevation is maintained within a plane superficial to the platysma muscle, to avoid injury
to the marginal mandibular branch of the facial nerve (10). When proceeding laterally, one must stay superior to
the superficial musculoaponeurotic system (SMAS), to further avoid facial nerve injury (11).
Once the cheek flap has been elevated, there are several key points for successful insetting of the flap, not only
to achieve the desired aesthetic result, but also to minimize the risk of postoperative complications. As the skin of
the paranasal region is somewhat thin, careful defatting of the subcutaneous tissue may be performed without
risk of damaging the subdermal vascular plexus, so that when the flap is inset, it will have the same thickness as
the original premorbid recipient site. Because of gravitational effects and flap weight relative to the lower eyelid
skin, suturing the flap undersurface to the periosteum of the zygoma is recommended, to prevent sagging of the
cheek and resultant ectropion of the lower eyelid.

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FIGURE 42.1 Cheek flap elevated.
FIGURE 42.2 Flap inset; the anterior border closes the defect, which does not extend into the nasal skin.
As the flap is sutured, skin excesses may appear on either side of the flap base. These can be excised as
Burrow's triangles or can be left and revised secondarily. The flap should not violate the side of the nose (Figs.
42.1, 42.2, 42.3).
CLINICAL RESULTS
Use of the cheek advancement flap for closure of superomedial defects has several advantages. First, flap
elevation requires a more limited dissection than rotation flaps to obtain the amount of skin advancement
necessary to effect defect closure. The defect is reconstructed with tissue that is similar in
color, texture, and thickness. However, male patients must be advised that the advancement flap may
elevate the facial hair line. The scars situated in the nasolabial fold are not particularly noticeable.

FIGURE 42.3 Flap heals with minimal evidence of scarring.
The development of postoperative ectropion can be minimized by suturing the flap undersurface to the
periosteum of the zygoma.
SUMMARY
The cheek advancement flap can be utilized to close moderately sized defects of the paranasal region. With
careful planning, design, and execution, excellent function and aesthetic results can be achieved.
References
1. Friedman M. Operative techniques in otolaryngology—head and neck surgery: facial flaps and facial
reconstruction, vol. 4. Philadelphia: Saunders, 1993;31-34.
2. Jackson IT. Local flaps in head and neck reconstruction. St. Louis: Mosby, 1985;223.
3. Zide BM, Jelks GW. Surgical anatomy of the orbit. New York: Raven, 1985;36.
4. McCarthy JG. Plastic surgery. Philadelphia: Harcourt Brace Jovanovich, 1990;2038.
5. Williams PL, ed. Gray's anatomy. New York: Churchill Livingstone, 1989;736-746.
6. Cameron RR. Nasolabial and cheek skin flaps. In: Strauch B, Vasconez L, Hall-Findlay E, eds. Grabb's
encyclopedia of flaps. Boston: Little, Brown, 1990;146-147.
7. Gunter JP, Sheffield RW. Transposition cheek skin flaps: the rhombic flap and its variations. In: Strauch B,
Vasconez L, Hall-Findlay E, eds. Grabb's encyclopedia of flaps. Boston: Little, Brown, 1990;337.
8. Corso PF. Variations of the arterial, venous, and capillary circulation of the soft tissues of the head by
decades as demonstrated by the methyl methacrylate injection technique and their application to construction
of flaps and pedicles. Plast Reconstr Surg 1961;27:180.
9. Crow ML, Crow FJ. Resurfacing large cheek defects with rotation flaps from the neck. Plast Reconstr Surg
1976;58:196.

10. Kaplan I, Goldwyn RM. The versatility of the laterally based cervicofacial flap for cheek repairs. Plast
Reconstr Surg 1978;61:390.
11. Mitz V, Peyronie M. Superficial musculoaponeurotic system (SMAS) in the parotid and cheek area. Plast
Reconstr Surg 1976;58:80.

Chapter 43
Nasal Plus Nasolabial Skin Flaps for Reconstruction of The Nasal
Dorsum
J. W. SNOW
EDITORIAL COMMENT
Procedure should be considered as a second option, if the forehead flap is not available.
The use of an L-shaped skin flap with its base straddling the midline at the root of the nose and its distal aspect
overlying the lateral aspect of the nasal pyramid has been found effective for reconstruction of the caudal half of
the nasal dorsum following tumor excision. The donor site is closed with an L-shaped nasolabial skin flap.
Both these flaps have good vascularity, as well as the proper skin color match and thickness. The lines of inset
fall within the natural lines of the nose and nasolabial region. This technique is different from a bilobed flap,
which shares a mutual base (see Chapter 35).
OPERATIVE TECHNIQUE
The underlying cartilage and bone may be planed if a hump is present in order to decrease the length of the
basic flap; i.e., the shortest distance between two points is a straight line. Removal of part of the cartilage and
bone may be done with impunity.
A lateral nasal defect remains where the tip of the nasal flap originated, and this can be closed by an adjacent
nasolabial skin flap that is tailored to fit the defect. The nasolabial flap donor site can be closed by approximation
of the wound edges.
FIGURE 43.1 A: The double L-shaped skin flaps have been outlined. A triangle of skin will be excised on the left
lateral nose, in order to accommodate the nasal flap. B: The L-shaped nasal skin flap has been rotated into the
dorsal nasal defect. C: The L-shaped nasolabial skin flap has been rotated into the lateral nasal defect and its
distal end trimmed. (Continued)

FIGURE 43.1 Continued. D,E: Result 4 months postoperatively.
The flaps have to be drawn with relative precision. The plane of dissection must be kept at a deep level, so that
the flap thickness corresponds to that of the defect and the blood supply is maintained. Two small fragments of
skin need to be excised (Fig. 43.1) to facilitate adaptation of the flap to the defect.
CLINICAL RESULTS
Over the last few years, six patients have presented appropriate defects for this method of reconstruction. It
has worked well in all six. If the defect is relatively large (2 cm), the nasal tip might be elevated somewhat as
a result of tension on the flap, but it gradually returns to its former position.
Care must be taken to prevent ectropion if the flap lies too near the lower lid. Slight shifting of the columella
toward the nasolabial flap side has occurred, but this gradually decreases with time.
SUMMARY
Reconstruction of the distal half of the nose can be accomplished using an L-shaped nasal flap for the
defect and an L-shaped nasolabial flap for the donor site.

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Chapter 44
Subcutaneous Pedicle Skin Flaps
J. N. BARRON
M. N. SAAD
EDITORIAL COMMENT
The Pers technique (Fig. 44.4) is a most elegant method using the nasolabial flap for reconstruction of
nasal rim defects. It is much safer when the subcutaneous pedicle is based on a known arterial blood
supply. The assurance of blood supply when performing the Pers technique for reconstruction of the alar
rim is not as precise when compared to the use of a flap with a definite vessel.
The subcutaneous pedicle skin flap consists of a skin paddle and a pedicle containing only subcutaneous tissue
(1, 2, 3). Three donor sites are available for nasal reconstruction: (1) the nose itself, (2) the nasolabial area, and
(3) the frontoglabellar region.
In the open technique, the donor and recipient sites are joined by an incision, and the flap is transferred under
direct vision. In the closed technique, the skin lying between the
donor and recipient sites is undermined, and the flap is transferred through a tunnel.
INDICATIONS
The nose, the nasolabial area, and the frontoglabellar region are all ideally suited for nasal reconstruction
because they provide good color and texture matches. Although subcutaneous pedicle flaps are less robust
than standard flaps, this is more than amply compensated for by their greater mobility and the small (but
obvious) advantage of avoiding an unsightly dog-ear at the base of the flap. Also, scarring that results from
the dissection of a subcutaneous pedicle is less than that which follows the use of a standard flap.
It is not advisable to repair very small defects with subcutaneous pedicle flaps, since there is the danger of
mushrooming. In such instances, a graft or standard flap is preferable.
Nasal skin itself is particularly useful for the repair of lining defects. Because the nose has very little skin to
spare, however, nasal skin defects alone are best reconstructed with flaps from the other two regions.
Subcutaneous pedicle flaps from the check adjacent to the nose can be used for the replacement of nasal
lining, as well as for repair of skin defects of the lower part of the nose, especially the alae. Coverage of
upper nasal, canthal, lower eyelid, and adjacent cheek defects is ideally performed with flaps from the
frontoglabellar region. Although standard forehead flaps can be used, they have the disadvantages of
limited mobility and the need for secondary correction of contour abnormalities at the base of the flap.
ANATOMY
It is not necessary to include an anatomically designated axial vascular system in the pedicle, although, if
available, this is an advantage. Many subcutaneous pedicle flaps rely on a random capillary circulation, and
because this is a low-pressure flow, it demands an ultra-atraumatic technique for dissection. We believe that the

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unilateral subcuticular suture disturbs the flap margin much less than ordinary interrupted sutures.
FIGURE 44.1 A,B: Design of the flap showing skin paddle and subcutaneous pedicle (closed technique). Note
that the circulation is random pattern, although axial vessels may be included in the pedicle in certain cases.
A direct vascular supply can be included with some subcutaneous pedicle skin flaps (4). Superiorly based
nasolabial flaps derive their blood supply from the supraorbital and supratrochlear anastomoses, and the
inferiorly based flap is nourished by the terminal branches of the facial artery or the superior labial vessels. Flaps
from the frontoglabellar region can include blood supply from the supratrochlear vessels.
FLAP DESIGN AND DIMENSIONS
The function of the pedicle is to transmit blood, lymph, and nerve supply to the flap. Thus a good pedicle design
is essential (Fig. 44.1). The pedicle should be long enough to allow the flap proper to reach the recipient site
without the slightest tension.
The pedicle also should contain sufficient vascular elements to sustain the viability of the flap and, if possible,
provide adequate sensation. The design should be such that kinking is avoided, and whenever possible, gravity
should help venous and lymphatic drainage.
It is important that the skin paddle be designed to fit the defect accurately, so that when suturing is completed, no
more tension exists than occurred in the original position. One should bear in mind that the size of a defect could
be larger than anticipated, as in the case of fibrosis in recurrent basal cell carcinoma following radiotherapy (Fig.
44.2).
The width of the pedicle should be as generous as possible, and the pedicle certainly should not be narrower
than that of the skin paddle. It is obvious that the shorter the length of the pedicle, the better. However, under no
circumstances should the pedicle be so short that the skin flap has to be sutured into position under tension.
The design of the subcutaneous pedicle skin flap is usually that of a transposition or advancement flap. Its
thickness will depend on local factors and vascularity.
OPERATIVE TECHNIQUE
After the flap and the subcutaneous pedicle have been outlined, the flap is incised through skin and
subcutaneous tissue along its distal and lateral margins and through skin only along its proximal margin. The
subcutaneous pedicle is then liberated in the subdermal plane by sharp dissection over
its full length. At this stage it is advisable to create a tunnel through which the flap and the pedicle will eventually
reach the recipient site. This tunnel should be generous in size and made by blunt dissection.

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FIGURE 44.2 A-G: Recurrent basal cell carcinoma on the left side of the nose, invading mucosal lining. Full-
thickness excision, using subcutaneous nasolabial skin flap for lining. Gillies' “bishop's miter flap” was used for
cover.
The deeper part of the flap and pedicle are then raised off the deep fascia, starting with sharp dissection and
then proceeding more proximally with blunt dissection. Finally, the two sides of the pedicle are divided with
scissors, thus completing the mobilization of the flap and pedicle. The flap is then picked up with skin hooks and
passed through the tunnel into the defect. Any tension at this stage can be released by further dissection of the
pedicle.
Meticulous hemostasis is imperative, and if necessary, suction drainage should be established. The donor area
is then sutured, avoiding any tension across the pedicle, and if required, a free graft is applied.
Flaps from the Nose
When used for lining, the flap is taken from the region immediately adjacent to the defect, dissected up on a
subcutaneous tissue base near the margin of the defect, and inverted into the cavity, where it is sutured to the

mucous membrane. Skin cover can be provided by nasolabial, frontoglabellar, or forehead flaps.
These small lining flaps have good viability, but they need an intranasal pack for 48 hours to support them and to
prevent a hematoma from forming between the two layers.
Flaps from the Nasolabial Area
Especially in elderly patients, fairly large flaps can be taken from the nasolabial area, leaving a linear
inconspicuous scar at the donor site. These flaps can be based superiorly or inferiorly (4, 5, 6, 7, 8, 9).
FIGURE 44.3 A-E: Full-thickness defect of alar margin. Superiorly based subcutaneous nasolabial skin flap
(open technique) was used for lining and then folded for external cover. Note that the base of the pedicle is up
toward the medial canthus.
The nasolabial pedicle can sometimes cause a noticeable fullness in the nasofacial groove, and occasionally,
this may require a later adjustment. However, if this is evident at the time of operation, an excision of the
paranasal subcutaneous tissue will allow the pedicle enough room to lie without causing an obvious bulge.
Nasolabial flaps can be raised from the region immediately adjacent to the defect, and in these cases, the
pedicle is designed so that the flap slides directly into its new position. This technique is particularly suitable for
defects of the alar base and margin (Fig. 44.3). A particularly elegant technique for repairing combined skin and
lining defects of the alar margin and alar base using nasolabial pedicle flaps was described by Pers in 1967 (9)
(Fig. 44.4).

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FIGURE 44.4 Pers technique for alar defect. Proximal portion of nasolabial subcutaneous pedicle flap was used
for lining. Remainder of flap was folded for external cover.
Flaps from the Frontoglabellar Region
There is a considerable amount of tissue available in this area for nasal reconstruction. With adequate
mobilization of the forehead skin and frontalis muscle, quite extensive secondary defects can be closed leaving
minimal, inconspicuous scarring (8, 10, 11) (Figs. 44.5 and 44.6).
CLINICAL RESULTS
Most flaps retain good color during the operation if the design is satisfactory. Some flaps become pale,
particularly if vasoconstrictors have been used with the local anesthetic. These pale flaps usually recover
and behave well unless a hematoma occurs.
Congested flaps result from improper technique that causes kinking or tension, and experience has shown
that congested flaps are those that will give the most trouble postoperatively. If a flap becomes congested
after insetting and suture, it is necessary to investigate, find the cause, and take corrective measures.
SUMMARY
Subcutaneous pedicle skin flaps can be ideal for nasal reconstruction, both for lining and cover. Flaps can
be taken from nasal skin itself (lining), the nasolabial area (lining and cover), and the frontoglabellar region
(cover).

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FIGURE 44.5 A-D: Basal cell carcinoma on the left side of the nose and lower eyelid. A sliding
(advancement) frontonasal subcutaneous pedicle flap based on the contralateral supratrochlear vessels
was used.
FIGURE 44.6 A,B: A similar, but larger defect repaired by transposition of a frontonasal subcutaneous
pedicle flap.
References

1. Andrews EB. Island flaps in facial reconstruction. Plast Reconstr Surg 1969;44:49.
2. Barron JN, Emmett AJJ. Subcutaneous pedicle flaps. Br J Plast Surg 1965;18:51.
3. Zook EG, Van Beek AL, Russell RC, Moore JB. V-Y advancement flap for facial defects. Plast Reconstr
Surg 1980;65:786.
4. Herbert DC, Harrison RG. Nasolabial subcutaneous pedicle flaps. Br J Plast Surg 1975;28:85.
5. Grate MR Jr, Hicks JN. Nasolabial subcutaneous pedicle flap. South Med J 1973;66:1234.
6. Herbert DC, DeGeus J. Nasolabial subcutaneous pedicle flaps. Br J Plast Surg 1975;28:90.
7. Herbert DC. A subcutaneous pedicled cheek flap for reconstruction of alar defects. Br J Plast Surg
1978;31:79.
8. Lejour M. One-stage reconstruction of nasal skin defects with local flaps. Chir Plast 1972;1:254.
9. Pers M. Cheek flaps in partial rhinoplasty. Scand J Plast Reconstr Surg 1967;1:37.
10. Converse JM, Wood-Smith D. Experiences with the forehead island flap with a subcutaneous pedicle.
Plast Reconstr Surg 1963;31:527.
11. Spira M, Gerow FJ, Hardy SB. Subcutaneous pedicle flaps on the face. Br J Plast Surg 1974;27:258.

Chapter 45
Nasalis Musculocutaneous Sliding Flaps for Nasal Tip
Reconstruction
F. J. RYBKA
Projecting like a masthead from the surface of the face, the nasal tip is subjected to more than its share of skin
cancers and trauma. Subcutaneous sliding flaps, including V-Y flaps, have been described for reconstruction of a
great number of areas about the face, almost to the exclusion of the nasal tip (1, 2, 3, 4, 5, 6, 7). These flaps are
generally based on a random-pattern subcutaneous blood supply, unlike the flap described herein.
INDICATIONS
The alar flap has some aesthetic advantages over vertical flaps, in that it follows the lines of the alar
groove, the natural crease line leading to the tip. Also, most tip lesions are not squarely midline, but
paramedian, and they are usually reconstructed using a lateral flap (Fig. 45.1).
Sliding flaps offer distinct aesthetic advantages over rotation flaps, because of the absence of both
redundant tissue (dog-ears) and chronic edema (8, 9).
ANATOMY
The facial muscles are unique in human anatomy, in that they have as their insertion the skin of the face. This
insertion may be more aponeurotic than muscular, as it is with the nasalis muscle.
The nasalis muscle originates, with several other facial muscles, from a common fibrous band in the nasolabial
fold. As it approaches the alar groove, the nasalis muscle is separated from the skin by subcutaneous fat, but as
it continues medially toward the tip (as an aponeurosis), it becomes intimately associated with the dermis of the
tip skin, with no layer of subcutaneous fat in between.
The nasalis muscle, like the tensor fasciae latae, is not much of a muscle, and it can be best demonstrated by
sniffing. This flap is one of the smallest musculocutaneous flaps described, and one might question if we are not
stretching terminology to classify it as a musculocutaneous flap at all.
However, similarities are readily found when we compare it with the tensor fasciae latae flap. Like the tensor
fasciae latae, its fascia is very long, with a ratio of perhaps one-fifth muscle to four-fifths muscle fascia. The
fascia of both muscles carries the axial blood supply with it, just as dependably as if the muscle were present.
Often, a distinct blood vessel, a perforating branch of the alar artery, can be identified as it penetrates into the
muscle base near the piriform process of the maxilla. The alar branch of the superior labial artery has been
determined to give off 7 to 12 branches every 2 mm or so as it courses around the base of the ala, following
closely the piriform aperture.
The nasalis branches penetrate this muscle and then follow it up the side of the nose, parallel with the alar
groove. In the aponeurosis, they finally anastomose with the branches of the alar artery from the opposite side.
FLAP DESIGN AND DIMENSIONS
Separation of the nasal skin from the cheek skin next to the alar base will allow a teardrop-shaped island,
anchored only by nasalis muscle and subcutaneous tissues, to advance up to 1.5 cm without risk. Bilateral
nasalis musculocutaneous sliding flaps can be used to close defects up to 2.25 cm wide.

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FIGURE 45.1 A: The typical defect is in a paramedian position on the nasal tip. The nasalis musculocutaneous
flap is designed with its caudal line right at the alar groove and the cephalad line determined by the width of the
defect. B: The flap is elevated down to the muscular attachments at the base of the piriform fossa. C: The flap is
advanced. Any small dog-ears resulting from the concave flap merging against a convex recipient area can be
excised. (From Rybka, ref. 8, with permission.)
OPERATIVE TECHNIQUE
The caudal incision of the teardrop-shaped flap is right in the alar groove; hence it blends in very well with
natural crease lines. The width of the flap is determined by the width of the defect. Thus the cephalad incision is
made from the upper pole of the defect to join the caudal incision adjacent to the alar base. It is important that
the flap extend all the way to the level of the alar base, since only there can the separation of skin from its
muscle and blood supply take place. More distally, this is all fused with the dermis of the skin flap.
FIGURE 45.2 A: A 32-year-old man with nodular basal cell carcinoma. Outline of planned resection. B:
Immediate reconstruction with the nasalis musculocutaneous flap. C: Result 3 months postoperatively. (From
Rybka, ref. 8, with permission.)
At the base, only the skin is completely divided, creating the island. The soft tissues are teased with a hemostat,
and the restraining fibrous bands are cut until the island is attached only by the deeper muscle, which includes

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the blood supply. The nasalis muscle is wider than the usual flap base, and it must therefore be dissected away
from the cephalad part of the flap. Advancement up to 1.5 cm should be accomplished without much difficulty
(Fig. 45.2).
FIGURE 45.3 A: An 80-year-old woman with a large basal cell carcinoma. The areas of resection and bilateral
nasalis flaps are outlined. B: The bilateral nasalis musculocutaneous flaps are elevated. C: The immediate
closure. D: Result 3 weeks postoperatively. (From Rybka, ref. 8, with permission.)
CLINICAL RESULTS
Over the past 10 years, 47 patients have had the nasal tip reconstructed with this flap. The majority of
these followed the excision of a basal cell carcinoma (40 of 47).
The maximum diameter of the defect reconstructed by the single flap was 1.25 cm. In six patients, a bilateral
flap was used, and this allowed reconstruction of a defect 2.0 cm in diameter (Fig. 45.3). In a few patients, a
limited rhinoplasty was performed to diminish the size of the defect. In such cases, one must be absolutely
certain that all tumor has been completely removed.
SUMMARY
An alar island sliding flap that is ideally suited to nasal tip reconstruction is described. It is actually a small
musculocutaneous flap based on the nasalis muscle. Tip defects up to 1.5 cm in diameter can be
reconstructed with a unilateral flap, and defects up to 2.25 cm in diameter can be reconstructed with a
bilateral flap.
References

1. Herbert DC, Harrison RG. Nasolabial subcutaneous pedicle flaps: I. Observations on their blood supply. Br
J Plast Surg 1975;28:85.
2. Herbert DC, DeGeus J. Nasolabial subcutaneous pedicle flaps: II. Clinical experience. Br J Plast Surg
1975;28:90.
3. Herbert D. A subcutaneous pedicled cheek flap for reconstruction of alar defects. Br J Plast Surg
1978;31:79.
4. Trevaskis AE, Rempel J, Okunski W, Rea M. Sliding subcutaneous pedicle flaps to close a circular defect.
Plast Reconstr Surg 1970;46:155.
5. Esser FJS. Island flaps. NY State J Med 1917;106:264.
6. Kubacek V. Transposition of flaps on the face on a subcutaneous pedicle. Acta Chir Plast 1965;2:108.
7. Zook E, Van Beek A, Russell R, Moore J. V-Y advancement flaps for facial defects. Plast Reconstr Surg
1980;65:786.
8. Rybka FJ. Reconstruction of the nasal tip using nasalis myocutaneous sliding flaps. Plast Reconstr Surg
1983;71:40.
9. Staahl TE. Nasalis myocutaneous flap for nasal reconstruction. Arch Otolaryngol Head Neck Surg
1986;112:302.

Chapter 46
Wraparound Cartilage Flap for Correction of Cleft-Lip Nasal
Deformity
I. J. PELED
Y. RAMON
Y. ULLMANN
EDITORIAL COMMENT
This is another technique that attempts to obtain symmetry of the normal alar cartilage with a slanted one
from a cleft-lip deformity. A satisfactory and similar result can be obtained with the free use of a cartilage
graft as an onlay procedure.
A turnover contralateral lower lateral alar cartilage flap is suggested for the correction of cleft nose alar deformity.
The flap wraps around the deficient medial crus and acts as a pulley, repositioning and augmenting the affected
alar cartilage.
INDICATIONS
Cleft-lip nasal deformity includes lateral displacement of the medial crus, as well as depressed and laterally
deflected lower lateral alar cartilage. In addition, there is a relatively larger, retrodisplaced naris, with
deviation of the nasal tip to the noncleft side. Definitive correction of cleft-lip nasal deformity is difficult to
achieve, and there is no ideal surgical procedure for all deformities (1, 2, 3, 4). The technique presented
repositions the affected lower lateral cartilage and augments and suspends the medial crus to make the
nasal tip as symmetrical as possible.
OPERATIVE TECHNIQUE
Under local or general anesthesia with local infiltration, an open nasal approach is carried out with a V-shaped
columellar incision. This enables direct visualization and appreciation of the degree of deformity. In cases of a
short columella, the V-to-Y closure of the incision offers a 2 to 3 mm increase in columellar length. After the
incision has been completed and the medial crura identified, the cartilage is exposed with bilateral rim incisions.
Horizontal markings determine the proposed height of the alar cartilage (Fig. 46.1A).
The cephalic portion of the contralateral alar cartilage is incised up to the medial dome, and is completely
released from the mucosal side as a medially based alar cartilage flap (Figs. 46.1B and 46.2A). The marked
cephalic portion of the alar dome on the cleft side is resected and put aside for a tip graft, if additional tip
projection is necessary. The remaining alar dome is released from the mucosal side only in the medial portion of
the dome, and the flap is brought under it (Figs. 46.1C and 46.2B), turned around in front, and finally sutured to
the contralateral side with 5-0 nylon (Figs. 46.1D and 46.2C).
The flap pulls the alar cartilage of the cleft side medially, and gives additional projection to the depressed dome.
When additional tip projection is necessary, a tip graft is placed above both domes and secured into position with
5-0 nylon. When necessary, other procedures are performed on the upper

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cartilage, nasal bones, and septum. On completion, skin incisions are sutured with 6-0 nylon.
FIGURE 46.1 A: Normal (left) and deformed (right) alar cartilages. Broken line marks flap incision and hatched
area is portion to be excised. B: Medially based alar cartilage flap. C: The flap is tunneled between the medial
crus and nasal mucosa. D: The flap wraps around the medial crus and is sutured to the normal side.
CLINICAL RESULTS
Satisfactory and long-lasting results were obtained in our small series, justifying this approach for the
improvement of cleft nasal deformities. Patients were satisfied with the procedure and pleased with the
cosmetic result (Fig. 46.3).
FIGURE 46.2 A: Left cartilage flap suspended with hook. B: Forceps tunneled behind the medial crus for
grasping the flap. C: The flap wraps around the right medial crus and is sutured to the left alar cartilage.
FIGURE 46.3 A: Preoperative frontal view. B: One year following surgery.

SUMMARY
The turnover contralateral cephalic alar cartilage flap is a good solution for the correction of cleft nose alar
deformity.
References
1. Humby, G. The nostril in secondary harelip. Lancet 1938;1:275.
2. Barsky, AJ. Principles and practice of plastic surgery. Baltimore: Williams and Wilkins, 1950.
3. Whitlow DR, Constable, JD. Crossed alar wing procedure for correction of late deformity in the unilateral
cleft lip nose. Plast Reconstr Surg 1973;52:338.
4. Ribeiro, L. Revising the nasal tip: a new approach. Plast Reconstr Surg 1989;84:671.

Chapter 47
Columella and Nasal Septum Skin-Cartilage Flap to Nasal Ala
M. ORTICOCHEA
EDITORIAL COMMENT
This is an elegantly conceived procedure that is applicable to smaller defects, but there are several
problems, including wound contraction and retraction, the possibility of producing asymmetry with the
opposite side, the lack of color match, the unpredictability of the alar roll, and retraction of the columella.
Defects of the ala nasi are common, and many methods have been proposed for their repair. The following
technique provides a repair of good shape, color, and texture and supplies sufficient cartilage to prevent the ala
from collapsing during inhalation (1).
OPERATIVE TECHNIQUE
An anteriorly based flap is raised that consists of half the columella and the membranous septum, the medial crus
of the alar cartilage, and as much of the skin lining from the cartilaginous septum as may be required (see Figs.
47.2 and 47.4). The medial crus of the alar cartilage is divided, producing a mobile flap that can be transposed
readily and sutured into the alar defect.
FIGURE 47.1 A,B: The alar defect. (From Orticochea, ref. 1, with permission.)
The donor area is covered with a skin graft. The tissues are fairly stiff, and little deformation occurs. With smaller
defects, the raw surface of the flap (inside the nostril) may be allowed to heal by secondary intention, and this
may impart a natural roll to the reconstructed alar margin. With larger defects (Figs. 47.1, 47.2, 47.3, 47.4, 47.5),
the flap as well as the donor area is skin-grafted.
Three weeks postoperatively, the patient is fitted with an intranasal prosthesis and continues to wear it for 3 to 6
months or until all contraction has ceased.
SUMMARY
The nasal ala can be reconstructed with a columella and nasal septum skin-cartilage flap.

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FIGURE 47.2 A-C: The flap is outlined. The incision passes along the midline of the columella and then
into the nasal vestibule and back toward the nasal tip. The exact size and shape depend on those of the
defect. (From Orticochea, ref. 1, with permission.)
FIGURE 47.3 A: The flap includes the medial crus of the alar cartilage, and when this is divided, the flap is
readily mobilized. B: The transposed flap used to reconstruct the right ala. (From Orticochea, ref. 1, with
permission.)
FIGURE 47.4 A: The flap has been raised, and the arrow marks the site where the medial crus of the alar
cartilage has been sectioned. B: The flap and the donor site have been covered with a skin graft held in
place with small quilting sutures. C: The flap is transposed into the alar defect. The arrow indicates the
vascular pedicle. (From Orticochea, ref. 1, with permission.)

FIGURE 47.5 A-C: The final result. (From Orticochea, ref. 1, with permission.)
Reference
1. Orticochea, M. Repair of defects of the ala nasi with a flap from the columella and nasal septum. Br J Plast
Surg 1978;31:176.

Chapter 48
Tissue Expansion in Nasal Reconstruction
L. C. ARGENTA
EDITORIAL COMMENT
The attractiveness of expansion of the forehead skin for nasal reconstruction should be weighed against
the following difficulties: loss of pliability of the skin flap owing to capsular formation, increasing thickness
of the flap, and the need for a multistaged procedure. In most nasal reconstructions, the secondary
forehead defect can be closed primarily, or if a small raw area is left open, it will heal by contracture with an
acceptable scar.
See Chapter 11 for a detailed description of the indications, flap design, operative technique, and clinical results
of tissue expansion for scalp and forehead defects.
CLINICAL RESULTS
In one patient who underwent expansion of forehead skin for total nasal reconstruction, there was some
mild tissue contraction because of inadequate structural support. Once the cantilever bone graft was
placed, no further contraction was observed (Fig. 48.1).
FIGURE 48.1 A: A 34-year-old man with a cavernous hemangioma of the central third of the face. The nose
was debrided to periosteum, and a split-thickness skin graft was used for initial closure. B: Multiple
expanders were placed in the face and expanded over 10 weeks. C: The patient 1 year after completion of
the excision and advancement of the flaps. The sutures in the forehead are in an area where a small dog-
ear required resection after 1 year when it did not subside.