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Although a limited transposition of nasal skin is possible, the flap works because the nasal tip is elevated at the
time of wound closure, effectively reducing the distance the flap has to be moved.
CLINICAL RESULTS
A minor problem has been the different thicknesses of skin in the flap. The thin skin of the epicanthal region
is moved downward into the thicker skin of the nasal area. Thick forehead skin also may have to be sutured
to thin epicanthal eyelid skin. If careful skin approximation is undertaken, there should be no great problem.
In fact, the resultant scar in the upper part of the nose is very acceptable (Fig. 49.1B).
It requires some fortitude to virtually lift the skin from the whole dorsum of the nose (Fig. 49.3B and C).
However, the cosmetic results are well worthwhile. There have been very few cases in which any flap loss
has occurred. Excessive tension is usually the main cause of trouble, and it was felt that the use of
epinephrine may have contributed to small losses at the flap tip in one or two patients. Epinephrine certainly
causes prolonged pallor of the flap, which can be quite worrisome.
SUMMARY
The lateral nasal flap can be effectively used to close defects up to 2 cm in diameter at or near the nasal tip.
FIGURE 49.1 A: This patient had radionecrosis of the nasal tip. B: Six months after closure of the central
nasal tip defect with a lateral nasal flap. Note the minimal scarring. (From Rieger, ref. 1, with permission.)
FIGURE 49.2 A: Initial incisions for the circular removal of a nasal tip lesion and the raising of a lateral

nasal skin flap. B: Flap lifted off the nose. C: Flap sutured in place. Note the combination V-Y and Z-plasty
closure in the glabellar region. (From Rieger, ref. 1, with permission.)
FIGURE 49.3 A: Patient with two basal cell carcinomas on the side of the nasal tip. B: Lateral nasal flap
marked out. The smaller and inferior basal cell carcinoma was excised and the wound edges approximated.
The flap was used to close the defect resulting from excision of the larger tumor. C: The flap includes
almost all the skin of the nose. D: The flap has been moved and the wounds sutured.
References
1. Rieger RA. A local flap for repair of the nasal tip. Br J Plast Surg 1967;40:147.
2. Marchac D, Toth B. The axial frontonasal flap revisited. Plast Reconstr Surg 1985;76:686.

Chapter 50
Axial Frontonasal Flap
D. MARCHAC
B. TOTH
This flap is a modification of the flap described by Rieger (Chapter 49) (1) with one fundamental difference. The
flap described, rather than being a random-pattern flap, is an axial flap with a well-defined vascular pedicle. This
allows for a much narrower pedicle and consequently more radical sliding and rotation of the nasal skin located
above the defect.
INDICATIONS
The axial frontonasal flap can be adjusted more precisely with what we feel is a better cosmetic result. The
donor site can be closed in a V-Y manner with the donor scar lying in a glabellar frown line. The flap is not
only ideal for reconstruction of defects at the base of the nose, but more important, it is able to provide a
sizable amount of skin of similar texture and color for the nasal tip as well. The scars are well hidden at the
sides of the nose or in the glabellar area. The flap is not recommended when the alar margin is involved (2,
3, 4).
ANATOMY
This flap is based on a vascular pedicle located at the level of the inner palpebral ligament (Figs. 50.1 and 50.2).
This pedicle is a branch of the angular artery, joining with the supraorbital arteries. It is well visualized on
arteriographic studies and cadaver dissections.
FIGURE 50.1 The axial flap is based on vessels emerging at the level of the inner canthus. This allows
increased mobility and precise adjustment. (From Marchac, Toth, ref. 6, with permission.)
FLAP DESIGN AND DIMENSIONS
Because of its axial nature, the flap can be transferred either with a narrow skin bridge or even as an island if
located on the side opposite to the defect (Fig. 50.3). A curved line is drawn from the defect along the side of the
nose passing medial to the canthal ligament and curving upward to follow a glabellar frown line. One should go
rather high on the glabella to avoid a dog-ear when closing and then go down in a frown line on the opposite
side toward the pedicle. When the defect is not centrally located, it is generally best to use the pedicle on the

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side of the pedicle defect since this gives the greatest flap length for reconstruction.
OPERATIVE TECHNIQUE
The dissection is best begun by undermining upward from the defect in the deep plane used in rhinoplasties,
below the muscle layer. The flap should initially be elevated on the side opposite to the pedicle. The
contralateral vascular pedicle will be seen during this stage and cauterized. In the glabellar region, only the skin
is lifted as the flap. One should then carefully dissect the pedicle side. If more laxity is needed, the skin incision
can be lengthened and the muscles tenting above and medial to the canthal ligament can be carefully separated.
FIGURE 50.2 Fresh cadaver dissection showing the pedicle of the frontonasal flap. (From Marchac, Toth, ref. 6,
with permission.)
FIGURE 50.3 The axis of rotation should be considered and the incision taken rather low on the lateral side of
the nose. (From Marchac, Toth, ref. 6, with permission.)
Undermining is performed at the periphery of the skin incisions, especially at the level of the tip and on the lateral
side of the nose opposite to the pedicle. The flap can then be adjusted to fit the defect. Especially when the
defect is on the lower part of the nose, one should carefully evaluate the axis of rotation of the flap and include
enough skin laterally on the side of the nose opposite to the pedicle to ensure closure without distortion.

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FIGURE 50.4 A: A 52-year-old woman with a basal cell carcinoma of the dorsum of the nose. Note how high the
frontal incision goes to avoid a dog-ear. B: After flap rotation and adjustment. C,D: Appearance 1 year
postoperatively. (From Marchac, Toth, ref. 6, with permission.)
The thickness of the edges of the flap must be adjusted at the lateral side of the nose and the inner canthal
regions. If too thick, the flap can be carefully thinned on its periphery. Careful approximation of the edges is
important. The resection of the dog-ear created by the rotation at the lateral side of the nose is the final stage
and should be generous (Figs. 50.4 and 50.5).
The wide exposure obtained through this approach permits modification of the framework. If a patient has a large
dorsal hump, the flap will often fit better if the hump is reduced in size.
CLINICAL RESULTS
Between 1969 and 1995, 150 patients underwent frontal nasal flap reconstruction for soft-tissue defects of
the nose. Half of the procedures were performed for defects of the upper half of the nose, while an equal
number were done for reconstruction of the nasal tip. Most of these flaps were performed for reconstruction
following excision for basal cell carcinoma (5, 6).

FIGURE 50.5 A: After excision of a recurrent basal cell carcinoma on a 61-year-old woman, the flap has
been incised. B: After rotation and adjustment. C,D: Two weeks postoperatively. There is moderate
shortening. (From Marchac and Toth, ref. 6, with permission.)
The survival rate of the flap was 100%; there was not even a partial loss at the tip. Only one recurrence
was noted 3 years following initial excision of a recurrent lesion after x-ray therapy. Following wide
reexcision, the same flap was able to be readvanced.
The aesthetic results were excellent. The most visible scar was on the lateral side of the nose up to the
inner canthus, mainly caused by the difference in skin thickness at this level. Some patients presented with
occasional redness of the tip of the flap. Since the frontonasal flap comes down with no tension, bringing
similar skin to the edge of the defect, the final lower scar is hardly visible, and there is no distortion.
SUMMARY
The axial modification of the fronto-nasal flap has expanded and refined its application in nasal defects.
References
1. Rieger RA. A local flap for repair of the nasal tip. Br J Plast Surg 1967; 40:147
2. Marchac D. Lambeau de rotation fronto-nasal. Ann Chir Plast Esthet 1970;15:44.
3. Marchac D, Al Khatib B. Les résultats à distance du lambeau fronto-nasal. Ann Chir Plast Esthet
1974;19:335.
4. Rigg BM. The dorsal nasal flap. Plast Reconstr Surg 1973;52:361.

5. Marchac D, Papadopoulos D, Duport G. Curative and aesthetic results of surgical treatment of 138 basal
cell carcinomas. J Dermatol Surg Oncol 1982;8:379.
6. Marchac D, Toth B. The axial frontonasal flap revisited. Plast Reconstr Surg 1985;76:686.

Chapter 51
Frontotemporal Flap
R. MEYER
EDITORIAL COMMENT
Reference (9) is recommended. It includes a historical perspective and elaborates on and compares the
various methods available.
This extremely versatile flap was introduced in 1952 (1) and was subsequently adapted by me for a variety of
reconstructive functions in the middle third of the face as well as in the orbital and periorbital areas (2, 3, 4, 5, 6,
7, 8, 9).
INDICATIONS
In experienced hands, the main advantages of the flap are (1) easy adaptability to the requirements of
shape and structure of the recipient site, (2) good color match, and (3) inconspicuous scarring at the donor
site. In my opinion, these advantages outweigh the fact that the procedure requires three stages.
With the addition of ear cartilage and split-thickness skin grafts to the flap, the tip, columella, septum, and
ala can be rebuilt to reproduce the external shape and internal structures of the defect. The most frequent
defect I have repaired with the frontotemporal flap is the loss of the tip and one ala caused by an animal or
human bite, trauma, or tumor excision.
For repair of the tip, columella, and both alae, either the frontotemporal flap or a composite flap from the ear
on a frontoparietal carrier flap is indicated (10, 11, 12, 13). I have also found the frontotemporal flap
adaptable for subtotal reconstruction of the nose.
FLAP DESIGN AND DIMENSIONS
The frontotemporal flap consists of two parts: a horizontal superciliary, or carrier, flap and a temporal portion that
represents the composite part of the flap used to replace the missing structures at the recipient site. The carrier
flap can be cut as narrow as 5 mm in the cutaneous layer, but by beveling the incision on both sides, a
subcutaneous flap width of approximately 10 mm is possible.
A defect of the entire ala extending to the upper lateral cartilages, as well as to the lower border of the nasal
bone, requires a broad triangular flap at the temple that has to be lined over nearly its entire inner surface.
The lobulocolumellar loss of tissue can include the anterior part of the septum with the lamina quadrangularis, in
addition to the columella and the membranous septum. In such instances, the prefabrication at the temple must
be composed of a three-layered quadrangular, rectangular, or trapezoidal plate destined to rebuild the septum,
as well as of an anterior pillar simulating the columella and tip (Fig. 51.1).
In cases of loss of the tip and one ala as a result of animal or human bite, trauma, or tumor excision, I outline the
flap at the temple in the shape of a crescent. On its concave side, a pocket is formed in the subcutaneous tissue
and lined with a split-thickness skin graft. To obtain a prominent tip, the cartilage graft inserted in the very
superficial subcutaneous pocket at the temple is shaped with a pronounced convexity.

For filling a defect limited to the ala, I usually choose a composite graft from the concha or the crus helicis of the
ear. However, where I want to be absolutely sure that the consistency and color of the reconstructed part of the
ala will be the same as the other nostril, I use the frontotemporal flap (Fig. 51.2).
For repair of the tip, columella, and both alae, the reconstructive complex at the temple has to be outlined as a
flap in the shape of a trefoil, with a sheet of auricular cartilage extending into all three divergent lobes. Beneath
each of the two lateral lobes, a pocket is formed and lined with a split-thickness skin graft.
OPERATIVE TECHNIQUE
Because the thin bridge flap between the glabella and the temple cannot be rolled, it is covered on its raw side
with split-thickness skin graft (Figs. 51.1C and 51.2B and C). The superciliary defect can easily be closed by
undermining the frontal skin. Multiple horizontal incisions in the frontal fascia may facilitate approximation, and
deep anchoring sutures to the periosteum of the orbital rim minimize upward pull of the eyebrow. Since the
suture line runs parallel to the wrinkle lines, an acceptable scar can be expected in most cases. Atraumatic
technique and intradermal running sutures help to make the scar inconspicuous.
FIGURE 51.1 A: Total loss of tip, columella, and anterior two-thirds of the septum after automutilation. B,C:
Preparation of the composite frontotemporal flap with ear cartilage and buccal mucosal graft. D: Transfer of the
flap. E: End of the third stage. F: Late postoperative result. (From Meyer, Kesselring, ref. 9, with permission.)
In the first stage, the part of the nose to be reconstructed is virtually prefabricated in the temporal area. Be it tip,

ala, columella, anterior septum, or part or all of the four, the missing feature can be outlined, with or without the
inner lining but practically always with cartilaginous support, and prepared with its inherent structures in the
temporal area.
The cartilaginous support, which is taken from the auricular concha and has already been trimmed to the
appropriate shape, is placed between the external skin and the vestibular lining in a superficial subcutaneous
pocket at the temple. In a deeper pocket, I place a split-thickness skin graft that will provide the recipient site with
vestibular lining. In cases of reconstruction of the tip and both nares, I prepare two independent pockets on each
side of the outlined flap. These become the vaults of the two nares. Small split-thickness skin grafts are applied
to these pockets and held in place with ointment gauze bolus dressings.
Two to 3 weeks later, the prefabricated tip-ala complex is transferred to the recipient site by means of the carrier
flap. The pedicle is sectioned or occasionally used for retouches at the recipient site, in a third stage, another 2
to 3 weeks later.
Although the donor site in the temporal area can, on occasion, be closed primarily by advancement of the
undermined skin edges, it is usually necessary to close the defect with a preauricular rotation flap. If there is
persistent traction of the lids or a distortion of the temporo-orbital region, a supplementary correction can be
performed during the third stage of the reconstruction.
A defect of the entire ala extending to the upper lateral cartilages, as well as to the lower border of the nasal
bone, requires a broad triangular flap at the temple that has to be lined over nearly its whole inner surface. Thus
a pocket deep under the cartilage graft is developed and lined with a split-thickness skin graft (Fig. 51.3).

FIGURE 51.2 A: Tip-ala defect after dog bite. B,C: Reconstructive complex in the right temporal region. D:
Transfer of the flap. E: Early postoperative result. F: Late postoperative result.
If only the columellar and lobular skin are lost, I use the composite graft mentioned earlier. However, such a
graft would not be sufficient if the membranous septum is also involved, In the latter case, I prefer to perform the
reconstruction using the frontotemporal flap, which is a simple, second bipedicle flap beside the superciliary
carrier flap in the same direction.
When the lobulocolumellar loss of tissue includes the anterior part of the septum, with the lamina
quadrangularis in addition to the columella and the membranous septum, the upper border of the nasal defect is
incised in the midline in a second stage, and the wound margins, as well as both alae, are spread laterally to
facilitate insertion of the compound flap into the nasal cavity. The anterior cut edge of the nostrils is sutured on
both sides to the apicocolumellar pillar in a third stage. The level of this insertion will determine the appropriate
triangular shape of the lower pyramid and the height of the nasal tip.
In nearly all cases of septocolumellar reconstruction, I have had to defat the septal component of the flap, which
must be thick enough primarily to ensure a sufficient blood supply. Since it seems to be too broad at the end of
the repair and represents a partial obstruction of the nares, the neoseptum has to be narrowed by resection of
subcutaneous tissue in a fourth stage.

FIGURE 51.3 A: Fresh dog bite injury in a child. B: Frontotemporal flap prepared after the first stage. C:
Postoperative result. (From Mendelson BC, et al., ref. 13, with permission.)
The lining for the septal plate can be provided by mucosal graft from the cheek instead of a split-thickness skin
graft to obtain a mucosal wall at least on one side. When a large amount of septal tissue has to be removed (as
in the case of tumor) and the columellar skin can be left intact, a flap from the temple may be brought to the
septum and interposed between the columella and the posterior edge of the perforating defect to push the tip
and columella in an anteroinferior direction. At a third stage, the divided carrier flap is inserted into the cavity to
fill an eventual remaining septal defect. This procedure allows the construction of a desirable straight profile and
prevents secondary retraction.
There are sequelae of multiple rhinoplasties in which progressive inelasticity from scarring of the covering
tissues precludes the insertion of cartilage or bone grafts. I have had to enlarge the cutaneous cover and, for this
purpose, choose the frontotemporal flap as the last resort for correction of such crucified noses. The temporal
portion of the flap is shaped as a trefoil, similar to that used for tip-ala-columella defects. At a second stage, the
scarred nasal skin is incised in the midline and spread to receive the flap. Since the scarred tissue at the
recipient site has a poor blood supply, the pedicle should not be severed for 3 to 5 weeks.
For subtotal reconstruction of the nose, a trapezoidal flap is outlined on both temples at a first stage. It is
reinforced with conchal cartilage graft and lined with a split-thickness skin graft. When the two frontotemporal
flaps are detached from the temple at a second stage, they are transferred to the defect and form both lateral
walls of the nasal pyramid. There they are sutured to the edge of the defect at the lateral border of the piriform
aperture and also are sutured together in the midline. If the septum is present, as in most cases of subtotal loss
of the nose, it will be incorporated as a supporting strut beneath the two joined flaps. One of the two superciliary
carrier flaps is used at a third stage for building the missing columella and for giving a better contour to the
dorsum of the nose. This three-stage procedure is valuable for subtotal repair, but it is not sufficient for total
reconstruction of the nose.
SUMMARY
The frontotemporal flap can be used to reconstruct various types of partial nasal defects.
References
1. Schmid E. Ueber die Haut-Knorpel-Transpiantationen aus der ohrmuschel und ihre funktionelle and

aesthetische bedeutung bei der deckung von gesichtsdefektenn. Fortschr Kiefer Gesichtschir 1961;7:48.
2. Meyer R. Rekonstruktion der nasenfluegel mit zusammengestztem ohrmuscheltransplantat. Monatsschr
Ohrenheilkd 1955;89:27.
3. Meyer R. Rinoplastica parziale con lembo frontale e frontotemporale. Minerva Chir 1960;15:1.
4. Meyer R. Die partielle ersatzplastik der nase. Helv ChirActa 1964;31:304.
5. Denecke HL, Meyer R. Plastic surgery of the head and neck, vol. 1: corrective and reconstructive
rhinoplasty. New York: Springer-Verlag, 1967.
6. Meyer R. Total nasal reconstruction. In: Conley J, Dickinson JT, eds. Plastic and reconstructive surgery of
the face and neck. New York: Grune & Stratton, 1972.
7. Meyer R. Nasal-septal perforation and nostril stenosis. In: Goldwyn R, ed. The unfavorable result in
plastic surgery. Boston: Little, Brown, 1972.
8. Meyer R, Kesselring UK. Reconstructive surgery of the nose and orbit. In: Sisson GA, Tardy EM, eds.
Plastic and reconstructive surgery of the face and neck, vol. 2. New York: Grune & Stratton, 1977.
9. Meyer R, Kesselring UK. Reconstructive surgery of the nose. Clin Plast Surg 1981;8:435.
10. Haas E, Meyer R. Konstruktive und rekonstruktive chirurgie. In: Gohrbandt E, Gabka J, Berndorfer A,
eds. Handbuch der plastischen chirurgie. Berlin: W de Gruyter, 1968.
11. Washio H. Retroauricular-temporal flap. Plast Reconstr Surg 1969;43:162.
12. Orticochea M. A new method for total reconstruction of the nose: the ears as donor areas. Br J Plast
Surg 1971;24:225.
13. Mendelson BC, Masson JK, Arnold PG, Erich JB. Flaps used for nasal reconstruction: a perspective
based on 180 cases. Mayo Clin Proc 1979;54:91.

Chapter 52
Midline Forehead Skin Flap (Seagull Flap)
D. R. MILLARD JR.
In ancient India, many centuries before Christ, the Kumas caste of potters cut forehead flaps for nasal
reconstruction following punishment mutilations. Since then, there have been many modifications of the original
design, but the seagull-shaped forehead skin flap has advantages that most of the other flaps do not enjoy.
INDICATIONS
The midline forehead skin flap (and its variations) can serve as cover for any nasal reconstruction from a
severe tip and alae loss to a total nasal defect (1, 2, 3, 4). Using this flap, an aesthetic and functional
reconstruction can be achieved by creating a nose that blends well with the face and enjoys patent bilateral
airways. It is important that the bridge and tip stand proudly, that the alae and columella contours are
sculptured, and that the scars are unnoticeable. An advantage of the seagull-shaped forehead flap is that it
is cut to cover regional units, thus hiding its tracks in light and shadows by camouflage.
ANATOMY
Since some glabellar and frontalis muscle fibers are included in this flap, it could be considered a type of
musculocutaneous flap. Its main vascular supply is the supratrochlear bundle based on the medial aspect of one
brow. The circulation to the distal portions of the flap is primarily random pattern.
FLAP DESIGN AND DIMENSIONS
The flap is best suited to a forehead of ample height (3 inches from brow to hairline). If the forehead is too
narrow, the flap can be set at an oblique angle. The design is created with the body of the seagull placed in a
midvertical position on the forehead (Fig. 52.1A). The tail, which is the base of the flap, is placed over one of the
supratrochlear vascular bundles.
The wings are spread out perpendicular to the axis of the body along the natural transverse lines of the
forehead. They are tapered at each end, and they are shaped wide enough to construct alae and long enough to
curl into the nostril floor as alar bases and nostril sills. The neck, head, and beak end of the flap are destined for
the nasal tip and columella. When local tissue is used for lining, this specific seagull pattern serves as ideal
cover in regional units for the bridge, tip, alae, and columella (Fig. 52.1B).
Designing the flap in both the horizontal and vertical axes reduces the amount of forehead taken in any one
plane. This facilitates primary closure in an inconspicuous midline T scar (Fig. 52.1C).
OPERATIVE TECHNIQUE
Although the flap could probably be transposed without delay, a surgical delay by incisions is advocated. This
can be accomplished when the local turnover flaps, which are usually based on scars, are delayed. If needed, an
L-shaped septal chondromucosal flap can be advanced for support at this initial stage (see Chapter 69).
The local flaps used for lining are turned over and carried down to the septal support. The midline forehead skin
flap is then elevated, transposed 180°, and sutured into position (Fig. 52.1B and C).
Division of the pedicle is safe after 3 weeks. As Sir Harold Gillies noted (5), division of the entire pedicle leads to

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edema of the reconstructed nose. If the vascular supply is left intact, however, edema does not occur as readily.
Therefore, only the skin portion is divided. Deep tissue is removed, if necessary, in order to preserve the
vascular pedicle. The skin pedicle is transposed back to the glabellar area to reseparate the brows and to
complete the bridge reconstruction as a unit.
FIGURE 52.1 A: The seagull-shaped flap is based on one of the supratrochlear vessel bundles. Its vertical axis
is placed over the midline of the forehead, and the wings are designed to lie in natural transverse creases. B:
Local flaps are turned over and carried down to septal support for lining. The forehead flap is elevated and
transposed 180° to cover the new nose. C: The body of the seagull lies along the bridge, the wings curl at the
alae and turn into the nostril sills, and the seagull head and neck area creates the tip and columella. Because
tissue is taken from two planes, the donor site can be closed in a T.
SUMMARY
A midline forehead skin flap designed in the shape of a seagull is an excellent method of reconstructing
both severe nasal tip losses and total nasal defects.
References
1. Millard DR Jr. Reconstructive rhinoplasty for the lower half of a nose. Plast Reconstr Surg 1974;53:133.
2. Millard DR Jr. Aesthetic aspects of reconstructive surgery. Ann Plast Surg 1978;1:533.
3. Millard DR Jr. Aesthetic reconstructive rhinoplasty. Clin Plast Surg 1981;8:169.
4. Millard DR Jr. Reconstructive rhinoplasty of the nose tip. Clin Plast Surg 1981;8:507.
5. Gillies HD. Plastic surgery of the face. London: Oxford University Press, 1920.

Chapter 53
Island Forehead Skin Flap
R. V. ARGAMASO
EDITORIAL COMMENT
This is an excellent flap for reconstruction of defects of the nose, which may require sacrifice of some
normal skin, but the end result is likely to be superior. The skin island in the forehead should be outlined as
high as possible to facilitate its transfer to the most caudad portion of the nose.
The superiority of forehead skin for nasal reconstruction is unquestioned. For a full-thickness skin replacement
of a sizable defect at the distal part of the nose, the island skin flap deserves practical consideration (1).
INDICATIONS
Distally, the skin of the nose is thick and contains numerous sebaceous glands. It drapes over the alar and
upper lateral cartilages that support the lobule and give definition to the nasal tip. Full-thickness skin loss
through trauma or disease results in a diminution of tip projection. Cicatricial contractures and secondary
deformities from skin-graft replacement with poor color match and thickness can become sources of great
embarrassment.
ANATOMY
A convenient pedicle for a forehead flap is supplied by the orbital branches of the ophthalmic artery. The
supraorbital artery is a branch of the ophthalmic vessel as it crosses over the optic nerve. It exits with the
supraorbital nerve through the supraorbital foramen and divides into superficial and deep branches. The
supratrochlear artery, a terminal branch of the ophthalmic artery, leaves the orbit at its medial angle and ascends
to the forehead near the midline.
These vessels anastomose freely with each other, with the frontal branch of the superficial temporal artery, and
with vessels from the opposite side of the forehead. This rich network of anastomoses ensures an adequate
circulation to a large skin island through a relatively narrow subcutaneous pedicle supplied by either one of these
orbital arteries.
FLAP DESIGN AND DIMENSIONS
The vertical dimension of the donor area of the forehead should be of sufficient length to provide a flap for easy
transposition and reach to the nasal tip. An outline of the nasal defect is drawn on paper and transposed
downside-up to the forehead donor area. The size of the outline transferred to the skin is slightly exaggerated to
increase the area, allowing for tissue shrinkage. Hair follicles are avoided.
Before the skin incision is made, a mock transfer is executed using a piece of gauze to simulate the pedicle. With
the inferior portion fixed at the point of rotation, the gauze is turned to the nasal defect to test the extent of the
arc of rotation.
From the midpoint of the inferior border of the skin island, a perpendicular line is drawn to the medial angle of the
orbit in the direction of the supratrochlear artery. This line will represent the direction in which a superficial skin

incision is made in order to develop the subcutaneous pedicle of the island skin flap (Fig. 53.1).
OPERATIVE TECHNIQUE
The superior and lateral borders of the skin island are deeply incised down to, but excluding, the galea.
However, the inferior border is incised down to dermis only. This superficial incision is extended in a vertical
direction to the medial orbital rim, following the skin marking. A subcutaneous pedicle approximately 2 cm wide is
developed by sharp dissection and elevated from the underlying galea. The pedicle base is extended as closely
as possible to the origin of the supratrochlear vessel as it emerges from the rim of the orbit.
FIGURE 53.1 A: Preoperative markings. B: Island pedicle incompletely dissected toward the origin of the
supratrochlear artery. C: Flap inset and donor area closed. (From Argamaso and Bautista, ref. 1, with
permission.)
FIGURE 53.2 A,B: A 45-year-old Filipina woman was referred for reconstruction of her nose. She had a history

of multiple silicone injections for augmentation of her nasal dorsum three years previously. A year later, the skin
of her nose became erythematous. Soon thereafter, despite surgical intervention, frank infection ensued,
resulting in skin necrosis in the alar regions. Subsequently, the patient underwent several reconstructions that
were complicated by infections and graft failures. These areas eventually healed with severe scarring. C: The
scarred areas were excised and the skin defect was repaired with an island flap from the paramedian area of the
forehead. D: Flap inset and donor site closed. E,F: The introduction of a subcutaneous pedicle on the dorsum of
the bony pyramid of the nose elevated the overlying skin and obliterated the frontonasal angle. However, this
drawback, inherent in the method, was welcomed by the patient, for it served to augment the low profile of her
Asian nose. A small bone graft eventually was added to enhance the reconstruction. Scar revisions also were
performed. (From Argamaso and Bautista, ref. 1, with permission.)
The nasal dorsal skin is elevated through the forehead incision, creating a tunnel through which the island skin
flap is introduced to reach the recipient site, where it is sutured in place. This tunnel should be wide enough to
contain the pedicle without strangulating its vessels.
The forehead donor site is closed by widely undermining the forehead skin, rotating a flap from one side of the
defect, and complementing it with an advancement flap from the opposite side (Fig. 53.2).
SUMMARY
An island skin pedicle flap of the forehead is a reliable and direct method for reconstruction of nasal defects.
It offers tissue of similar texture and color to the skin of the distal portion of the nose.
Reference
1. Argamaso RV, Bautista BN. Partial and total nose reconstruction. Phil J Surg Spec 1981;36:17.

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Chapter 54
Supratrochlear Artery (Off-Midline) Forehead Skin Flap
I. K. DHAWAN
N. C. MADAN
EDITORIAL COMMENT
The robust blood supply to the forehead does not necessitate the inclusion of a distinct vessel. However,
more attention should be paid to the anatomic and visual units of the nose. Often, the best result is obtained
by reconstructing the entire aesthetic unit of the nose, even if it requires excising normal tissue.
A forehead flap that is located to one side of the midline and that extends to the hairline recess can be based on
one supratrochlear artery (1, 2, 3, 4).
INDICATIONS
This flap can provide enough skin to cover the nasal tip and two-thirds of the alae and the columella.
ANATOMY
The supratrochlear artery is a branch of the ophthalmic artery, and it leaves the orbit at its superomedial aspect.
In the forehead, it runs vertically, accompanied by its vein, into the hairline recess.
FLAP DESIGN AND DIMENSIONS
The base of the flap, that includes the supratrochlear vessels, is at the orbital margin, near the medial end of the
eyebrow. The carrier segment is between 0.5 and 1.0 cm wide. When the flap is turned to cover nasal defects,
the pivot point is at the lateral side of the base, and the flap arcs through 180°. The length of the flap depends on
the height of the browline and the depth of the hairline recess. The paddle is designed to fit the defect and can
be “flagged” to one side of the carrier segment. The position of the paddle is determined by the hairless skin
available on either side of the vessels (Fig. 54.1).
OPERATIVE TECHNIQUE
The supratrochlear artery is marked preoperatively either by palpation or by use of a Doppler flowmeter. The flap
is raised in the loose areolar plane above the periosteum down to the orbital
rim, taking care not to damage the vessels at the base. The defect left by the carrier segment is closed in two
layers, and that left by the paddle, if large, is covered by a postauricular full-thickness skin graft. The raw surface
of the carrier segment is covered by a split-thickness skin graft, since it is too narrow to be tubed.

FIGURE 54.1 A: The flap paddle may be “flagged” on one side if the artery is close to the hairline. B:
Alternatively, the paddle may be placed uniformly on either side of the vessel. (Continued)
FIGURE 54.1 Continued. C: For nasal defects, the arc of rotation is 180°. D: A small donor site defect can be
closed by direct approximation of the wound edges, larger donor site defects may require a postauricular skin
graft.
It is not advisable to carry the flap on a subcutaneous pedicle, since this leaves a ridge on the nasal bridge and
produces venous compression and flap edema. The carrier segment is sectioned between 18 and 21 days,
reinserting only the proximal portion as a triangle to restore eyebrow alignment.
CLINICAL RESULTS
The supratrochlear artery forehead skin flap has been used to repair 17 defects of the nose. There has
been no loss of the flap, and it has provided well-matched skin of good texture. The defect has been
satisfactorily reached, and the residual defect in the hairline recess has been minimal (Figs. 54.2 and 54.3).
The flap is not suitable for reconstruction of the entire nose, nor can it be used in individuals with a very low
hairline.

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FIGURE 54.2 A partial defect of the nasal tip, alae, and columella with the supratrochlear artery skin flap
raised.
SUMMARY
An off-midline forehead flap based on one supratrochlear artery and vein has been described for
reconstruction of partial nasal tip defects.
FIGURE 54.3 Postoperative view of a patient.
References
1. Dliawan IK, Aggarwal SB, Hariharan S. Use of an off-midline forehead flap for the repair of small nasal
defects. Plast Reconstr Surg 1974;53:537.
2. Kazanjian VH. The repair of nasal defects with the median forehead flap: primary closure of the forehead
wound. Surg Gynecol Obstet 1946;83:37.

3. Richardson GS, Hanna DC, Gaisford JC. Midline forehead flap: nasal reconstruction in patients with a low
browline. Plast Reconstr Surg 1972;49:130.
4. Sawhney CP. Use of a longer midline forehead flap for rhinoplasty, with new design of closure of the
donor site. Plast Reconstr Surg 1979;63:395.

Chapter 55
Axial Paramedian Forehead Flap
G. C. BURGET
EDITORIAL COMMENT
This chapter combines both the art and science of plastic surgery with very gratifying results.
A vertical, axial paramedian forehead flap is the donor tissue of choice for nasal reconstruction. However, in
some situations it is not ideal. It is thicker than the normal skin of the nasal dorsum, and when it is used to
resurface this subunit it produces a greater aquiline hump than the original nose possessed. Because it is
somewhat rigid, forehead skin is not an ideal replacement for the alar lobule. The soft skin of a nasolabial flap
more easily forms itself into a blob, which resembles the normal convexity of the alar subunit. In children, the
upper half of the forehead is covered with fine lanugo hairs. These hairs become thick when they are denervated
causing the forehead flap nose to be fuzzy during the first year following reconstruction. Nevertheless, the
paramedian forehead skin is the ideal replacement for nasal tip skin, and may be used successfully to restore
any part of the nose.
ANATOMY
As shown by McCarthy and associates (1), vertical branches of the angular and supratrochlear arteries cross the
superior orbital rim in the region of the wrinkle line that lies perpendicular to the corrugator muscle. They cross
the orbital rim deep to the frontalis and corrugator muscles and rapidly enter the subcutaneous layer as they
ascend the forehead. In the upper half of the forehead, many fine branches of the arteries lie in the
subcutaneous fat close to the dermis. The entire frontalis muscle and some of the subcutaneous fat may be
removed from the distal end of a paramedian forehead flap without injuring its axial arteries.
FLAP DESIGN AND DIMENSIONS
The many modifications of the forehead flap have been designed to increase its length, so that columellar
defects may be covered, or to enlarge its surface area, so that the total nose may be resurfaced. Nonvertical
variations, such as New's sickle flap or Gillies' up-and-down flap, deprive the forehead flap of its axial quality.
Converse's scalping flap is large enough to cover the entire nose, but as the name implies, it increases the
patient's morbidity. In truth, the classical vertical paramedian forehead flap will cover the entire nose from radix to
columellar base without the necessity for extravagant variations or mechanical forehead tissue expansion.
After millennia of experience, new principles continue to emerge:
1. The flap is designed vertically and axially. This makes it vascularly robust, so that it may be radically thinned
and depilated.
2. The base of the flap is made no wider than 1.5 cm for easy mobility without strangulation.
3. The base of the flap is positioned to include a branch of the angular-supratrochlear arteries, which is located
with the Doppler pulse amplifier.
4. Additional length is attained by extending the flap's proximal end across the orbital rim or its distal end into the
hair-bearing scalp.

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5. The flap is not designed to fit the nasal defect, for the nasal defect, distorted by edema, scar contraction, and
local injections, does not represent what is missing from the nose.
6. An exact three-dimensional pattern of nasal surface subunits taken from the contralateral normal side of the
nose or from an ideal model is used as a template for the flap's design.
7. No marginal excess of skin is included when the flap is incised. This minimizes centripetal flap contraction,
which obliterates surface contour.
8. Distal portions of the flap are thinned to the thickness of nasal tip skin and are depilated where necessary.
9. The base of the flap is excised and discarded, not replaced on the forehead.
0. The upper half of the donor defect is allowed to close by biologic wound contraction and forehead skin
autoexpansion. There is no necessity for skin grafts, local flaps, or mechanical tissue expansion to close this
secondary defect.
It requires the talents of a tailor to fashion a forehead flap. A flap cut too small collapses the cartilage framework
of the nose. A flap cut too full allows centripetal contraction to pull the excess skin into a blob, obscuring nasal
surface contour. The pattern for a made-to-measure forehead flap may be fashioned from heavy aluminum foil
such as that used to pack sutures.
There is a strong impulse to make the flap fit the nasal defect, as Millard has said (2), “to fill the hole.” However,
the defect that exists at the time of nasal reconstruction does not reflect the amount of skin missing from the
nose. It has been enlarged by edema and distorted by wound contraction and intraoperative lidocaine injections.
The shape of the defect is not the shape nor size of the missing part of the nose. Therefore, one should turn to
the remaining normal contralateral parts of the nose for a pattern. The nasal defect is sketched in mirror image
with methylene blue dye on the normal contralateral side of the nose, which is undistorted by inflammation or
injections. If the entire nose is missing, then a model of an ideal nose may be used to create a pattern for the
flap. The defect may be enlarged to cover entire topographic surface subunits of the nose (Fig. 55.1), especially
when convex regions such as the alar lobule, dorsum, hemitip, or tip subunits are to be replaced. A trapdoor
contraction occurs in the transplanted forehead tissue and the bulge of the entire subunit comes to resemble the
normal bulge of an ala, dorsum, hemitip, or tip.
FIGURE 55.1 It is sometimes wiser to replace an entire surface subunit with forehead flap tissue than merely to
patch the hole. Here the remaining normal skin of the tip subunit is excised following the borders of the alar
cartilages. A three-dimensional foil pattern is flattened to two dimensions and traced just below the hairline. No
marginal excess skin is taken with the exact-pattern flap. As postoperative centripetal (trapdoor) contraction

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occurs, the bulge of the flap will not disrupt the surface contour but will, in fact, resemble the normal bulge of the
nasal tip subunit.
The forehead flap is designed vertically to preserve its axial quality. Branches of the supratrochlear and angular
vessels are located with the Doppler pulse amplifier, and the base of the pedicle is then centered on these
vessels. This allows the proximal two-thirds of the pedicle to be designed very narrow without compromising its
blood supply. Assured of an axial blood supply, the flap may be thinned and depilated and thus may include up to
1.5 cm of hair-bearing scalp tissue for replacement of the columella. If the flap is designed on an angle as slight
as 15° off the vertical, it will cut across branches of the axial vessels, in which case thinning and depilation
become risky. It is better to maintain the vascular robustness of an axial flap and obtain the needed flap length
from the hair-bearing scalp than to gain length with an eccentric flap design. A vertical forehead flap in a non-
cigarette smoker will easily bear the rough treatment of thinning and depilation, while an oblique random
forehead flap may not be thinned and must therefore be applied to the surface of the new nose with all its
redundant layers of tissue.
The pattern of the missing surface subunits is designed in three dimensions from the remaining normal side of
the nose (or from an ideal model). After the exact location of vascular branches has been confirmed with the
Doppler pulse amplifier, the pattern is flattened to two dimensions and traced with methylene blue near the
hairline in axis with the supratrochlear vessels on the side of the nasal defect. A 1.5 cm columellar extension of
hair-bearing scalp may be included distally.
OPERATIVE TECHNIQUE
The base of the pedicle is traced 1.2 to 1.5 cm wide, and no wider, to allow axial rotation (twisting) without
strangulation. The proximal two-thirds of the pedicle may be quite narrow and then expand suddenly to
incorporate the pattern. When the flap is incised, the cuts are made on the inside of the blue lines so that not
even a half millimeter of excess skin is included. In its distal 2 cm, the flap is elevated superficial to
the frontalis muscle. Proximally, the frontalis muscle is elevated off the periosteum with the pedicle to protect the
axial vessels. If extra length is needed, corrugator muscle fibers are divided using magnifying loupes so that
vascular branches are preserved while restricting bands of muscle are released. If the flap still proves short, then
the pedicle is extended across the orbital rim, including a bit of the eyebrow if necessary. Again, it is helpful to
mobilize the pedicle by dividing corrugator muscle fibers while preserving vascular branches.
After the flap is elevated, its borders and its distal 2 cm are thinned using curved Joseph's scissors. Hair follicles
remaining in the distal part of the flap are clipped off with fine scissors under 2.5× magnification. During the
thinning, axial branches of the supratrochlear-angular arteries visible in the subcutaneous tissue very close to
the dermis are preserved. During thinning close attention is given to the nasal defect, since some of its regions
require more subcutaneous tissue than others, and the flap may be thinned accordingly. The thinned flap is
transported to the nasal defect. Right-sided flaps rotate clockwise; left-sided flaps rotate counter-clockwise. Key
sutures fix the flap in position. Fine sutures adjust its edges.
Suturing may be done in such a way as to enhance nasal contour. At the junction of the upper lip, the cheek, and
the alar groove, the flap is pulled inferiorly before the key stitch is placed (3). This forces the alar tissues to bulge
in a normal convexity and stretches the tissues of the lateral side wall so that they do not bulge. A no. 19 suction
drain may be placed under the forehead flap and hooked to a vacuum tube. The negative pressure created pulls
the various layers of the nose together during the postoperative phase.
The secondary forehead defect continues to vex surgeons. It has not been generally recognized that the
forehead is a forgiving donor surface. Although frequently it cannot be closed with sutures, nevertheless, skin

grafts, local flaps, or mechanical tissue expanders are not needed. In fact, they compound the deformity and
increase patient morbidity. The forehead defect that remains after local advancement of tissues will close
biologically by the process of wound contraction and forehead autoexpansion. These processes require neither
further incisions, pain, hospitalization, inconvenience, nor expense. They are performed without compensation by
the myofibroblasts. Any frontalis muscle remaining in the donor defect is removed. Then the forehead and scalp
surrounding the donor site are elevated from the periosteum of the frontal bone for 7 cm bilaterally and
superiorly. Two to four heavy simple sutures tied under moderate tension pull the limbs of the defect together.
These key sutures are placed close to the wound edge to minimize their stitch marks, since they will remain in
place for 10 days. Distal dog-ears are excised laterally and superiorly. The limbs of the defect are closed in
layers. Exposed periosteum in the central open region of the donor wound is protected from desiccation with
petrolatum gauze and ointment. No contraction occurs in the open defect for about 3 weeks. Then, during the
fourth and fifth postoperative weeks, the wound rapidly contracts, autoexpanding the adjacent skin and
producing a surprisingly forgiving result. Mechanical tissue expansion, local rotation or advancement flaps with
their necessary scars, or the postage-stamp application of a skin graft is unnecessary. These adjunctive
procedures actually increase patient discomfort, scarring, or contour deformities.
The raw posterior surface of the forehead pedicle may be left open. However, a thin split-thickness skin graft
applied to the back of the flap minimizes the problems of an open wound and the need for postoperative office
visits. The patient is instructed not to place spectacles on the flap, but rather to suspend them from the forehead.
A commercially available device known as Frame-Ups (Arox Company, P.O. Box 24740, Los Angeles, CA 90024)
allows the weight of the spectacles to rest on the cheeks. Nearly all skin sutures are removed between the
second and fourth postoperative days. The incisions are supported with 1/8-inch-wide skin tapes. The several
key tension-bearing forehead sutures remain until the tenth day, but since they have been placed close to the
skin edge, their stitch marks are minimal. The petrolatum gauze is removed from the open donor wound around
the fifth postoperative day. After that, a small bandage is kept over the defect until closure occurs in the fifth
postoperative week.
Postoperative complications of flap necrosis have been rare, except in patients who smoke cigarettes. Long-term
cigarette smoking appears to affect the arterial circulation of the forehead skin. Even cessation of smoking for
several weeks before surgery does not seem to change the vascular frailty of the skin flap. In operations on
patients who smoke, the Doppler pulse amplifier is used to identify and trace the course of distinct axial vessels
for inclusion in the forehead pedicle. Patients who have had facial radiation therapy for acne or hair removal
many years before are also likely to have wound problems. Patients with rhinophyma or numerous comedones
are at high risk for infection. In these patients, the use of benzoyl hydroxide and antibiotics preoperatively is
helpful. In severe cases, a preliminary dermabrasion of the forehead and nasal skin is done to reduce sebaceous
hypertrophy or the cystic nature of the skin.
An Intermediate Operation
In complex reconstructive cases, it is helpful to elevate the flap at an intermediate stage and shape the
underlying tissues. In 1974, Millard (4) advocated leaving the pedicle in place while making adjustments to the
nasal contour. At such an intermediate operation, the entire forehead flap is lifted off the subsurface framework
of the nose but remains attached along the nostril margin and at the columella distally, as well as to its pedicle
proximally. The elevated flap is thinned, additional cartilage grafts are added to the nasal framework as
necessary, and the subsurface structures are shaped to create an ideal nasal contour. In general, such an
intermediate operation has been necessary only in large restorations that involve more than half the nose.
Excision of the Pedicle
Twenty-one days after the nose was assembled, the skin pedicle is excised and discarded. If it were replaced on

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the forehead, it would remain permanently as a visible lump. Because of its narrow design, the pedicle may be
excised without fear that the eyebrows will be pulled together. Sufficient glabellar skin remains to ensure
satisfactory eyebrow separation. The proximal stump of the pedicle is thinned of fat and frontalis muscle. It is
inset as a small inverted V 8 to 10 mm high, just medial to the eyebrow. The distal part of the flap has an
increased vascular efficiency that allows it to be elevated off the nasal defect for 1.5 cm caudally. The cephalic
portion of the nasal flap is thinned, and the underlying nasal defect shaped to an ideal contour. Then the
transplanted forehead skin is trimmed to size and inset along the superior edge of the nasal defect. The nasal
flap, made rigid by subcutaneous scar,
is subject to postoperative hematoma and resultant abscess. For this reason, loosely tied quilting or basting
sutures of 5-0 or 6-0 material are placed through the flap to cause the donor skin to adhere to its recipient bed.
These sutures are removed within 48 hours. This has proven more effective than a vacuum drain placed
beneath the flap.
A CLINICAL CASE
One case is presented to demonstrate how lining flaps and hard-tissue grafts combine in one stage to form a
subsurface architecture over which a thin forehead flap is fitted to create the visual impression of a nose. The
patient (Fig. 55.2) was a 39-year-old woman who had a deeply invading basal cell carcinoma excised and was
referred for immediate reconstruction. There had been a full-thickness loss of the right nasal ala and hemitip and
a more superficial loss of parts of the left hemitip, nasal dorsum, and right lateral side wall.
The first of three surgical stages was undertaken on the day following surgical excision. At this first operative
sitting, the nasal lining sleeve was assembled, a framework of hard-tissue grafts was fused to its submucosal
surface, and a forehead flap was tailored and fitted over the framework.
The Nasal Lining Sleeve
Thin, flexible, vascular nasal lining flaps are in short supply. Thick lining flaps of skin and subcutaneous fat, such
as nasolabial flaps, are readily available, but they bulge inward and outward, destroying the nasal airway and the
nasal shape. Nasal lining flaps with poor vascularity, such as marginal turnover flaps, may themselves survive
but will not nourish the primary cartilage grafts required to impart contour and support to the rebuilt nose. Rigid
lining flaps, such as the composite grafts of skin and cartilage placed under a forehead flap weeks before it is
formed into a nose, become stiff and maintain whatever form they have assumed while on the forehead. The
shape of the new nose is then dictated by these preplaced lining grafts. The only nasal lining flaps that are at
once thin, supple, and highly vascular are intranasal flaps from the vestibule, the middle vault, and the nasal
septum.

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FIGURE 55.2 A,B: A basal cell carcinoma has been excised resulting in loss of the right hemitip and parts of the
left hemitip, dorsum, right side wall, and right ala.
The present case demonstrates the use of such ideal lining material. A bipedicled flap was designed on the
nasal lining just above the margin of this patient's defect (Fig. 55.3). The flap, 8 mm wide by 2.5 cm long, had its
medial base at the membranous septum where the medial and lateral crura of the alar cartilage meet. The lateral
base of the flap was located on the nostril floor, just behind the alar base. The flap, with an attached fragment of
alar cartilage, was freed with blunt scissors dissection from the overlying skin and nasal subcutaneous tissue.
The junction of the lateral and medial cartilaginous crura was divided preserving the bridge of vestibular skin,
which was the medial base of the flap. As this supple ribbon-like strip of tissue was brought down to the level of
the nostril margin, it formed folds and kinks. Nevertheless, it was a robust flap that could support the primary
cartilage grafts needed to splint the nostril margin and create the normal contour of a nasal tip and an alar lobule.
A secondary lining defect then existed above the nostril margin flap. A second lining flap, of contralateral
mucoperichondrium based on the dorsum of the septum and presumably receiving branches of the ethmoidal
arteries, was employed to line the middle nasal vault. (The ipsilateral mucoperichondrium was reflected caudally
and posteriorly.) The exposed cartilage and bone of the septum were left attached to the contralateral
mucoperichondrium in this case, but they might safely have been removed and replaced as a free graft. The
contralateral mucoperichondrial lining flap was incised on three sides but remained attached along the septal
dorsum. It was then hinged laterally and sutured to the lateral edge of the piriform aperture, as first described by
DeQuervain (5).
The cartilage remaining attached to this flap was scored vertically so that the flap could be arched into a vault for
the nasal airway (see Fig. 55.5). When sutured together with 5-0 catgut, the two lining flaps created a highly
vascular, thin, and pliable lining sleeve. Such a lining sleeve will provide neither rigidity nor contour to the new
nose until primary grafts of cartilage carved to resemble specific nasal topographic subunits are fused to its
submucosal surface. The technique employed in the present case, using ipsilateral and contralateral septal
flaps, results in a septal fistula. Although careful follow-up of many such fistulae has found that they become self-
cleaning
and asymptomatic, nevertheless, another lining technique is now preferred for small unilateral full-thickness
losses of the lower part of the nose.

FIGURE 55.3 A,B: The lining sleeve is assembled from a bipedicled alar margin flap mobilized from just above
the defect and a composite flap of septal cartilage and contralateral mucoperichondrium. This results in a septal
fistula. Primary bone and cartilage grafts added to this thin, supple, and highly vascular lining will give it rigidity
and a nasal shape. The vertical paramedian forehead flap is custom-fitted to the internal hard-tissue scaffold and
thinned until it is no thicker than normal nasal tip skin. (From Burget, ref. 8, with permission.)
Using the new technique (Fig. 55.4), the entire anterior septal mucoperichondrium, designed as a flap with a
narrow pedicle just over the nasal spine, can be employed as lining for the nasal vestibule and alar margin. Such
a flap consistently survives if it is based on a 1.3-cm pedicle located in a zone between the anterior plane of the
upper lip and the lower edge of the piriform aperture—the zone containing the septal branch of the superior labial
artery. The flap may extend from the nasal floor below to the level of the medial canthus above and posteriorly to
the ethmoid perpendicular plate.
Here are details of the technique (Fig. 55.4). The entire anterior septal mucoperichondrium is injected with
1:50,000 epinephrine solution, and after a few minutes, it is elevated off the septal cartilage and bone. The flap
is designed with a septal component and bipedicled component, which give it the shape of a hatband (the
bipedicled portion) into which a press card (the septal portion) has been stuck. When pivoted into position and
fixed there with 5-0 catgut sutures, this oddly shaped flap lines the new vestibule of the nose. The exposed
cartilage and bone of the septum are removed as in a submucous resection. The contralateral septal
perichondrium remains exposed in the donor defect and soon covers itself with transitional epithelium. This two-
component flap lines the lower one-third of the nose without creating a septal fistula.
A Shapely and Rigid Chassis
The flimsy vestibular lining sleeve is converted into a composite flap (Fig. 55.4). Cartilage and bone grafts are
carved with precision to mimic in microform the shapes of the surface subunits of the nose. When these
contoured grafts are fused to the submucosal-perichondrial surface of the lining sleeve, they cause it to expand,

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become stiff, and take on an ideal nasal shape (reduced by 2.5 mm in all dimensions) (Fig. 55.5). The lining
sleeve depends on the grafts for its rigidity and shape; the grafts depend for their life on contact with the
vascular lining. It is the shape of this fabricated composite flap that gives normality or beauty to the final visual
impression. Four different hard-tissue grafts are required for a major nasal restoration: a strut, a buttress, a
brace, and a batten. Each piece serves to fix the underlying mucosal lining in position. Each piece imparts a
shape to a specific surface subunit of the nose.
Here is how the internal scaffold was constructed:
1. The columellar strut. Cartilage from the wall of the concha measuring 4 mm by 3.5 cm was removed through
an anterior incision. This graft material was formed into a new alar arch incorporating the columellar-lobular
rotation angle of 50°. The strip of cartilage was sutured to the stump of the medial crus. Then it was scored,
bent, and sutured to the submucosa of the new right vestibular dome and to the medial crus of the normal
contralateral alar cartilage. A piece of septal cartilage was shaped into a small chamfered tip graft measuring 4
× 9 mm and sutured in an appropriate position to give optimal tip projection. It is not surprising that this whole
complex resembles the umbrella graft described by Peck (6), for it serves an identical purpose.
FIGURE 55.4 A-C: An alternate method for assembling lining is the use of the septal pivot flap. A rectangular
septal mucoperichondrial component and a bipedicled nostril margin component are both based medially on a
pedicle containing the septal branch of the superior labial artery. As they pivot forward, the exposed cartilage
and bone of the septum are removed for graft material. The contralateral septal perichondrium is left bare in
the donor site. Three of the four hard-tissue grafts were used in the present case. Each graft was modeled to
resemble in microform a nasal surface subunit.

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2. A flying buttress for the nasal bridge. A piece of septal cartilage may be needed to supply a replacement for
the lower nasal bridge. It acts as a flying buttress between the distal septum and nasal tip to prevent snubbing
of the nose. In the present case, the nasal bridge was intact, and a flying buttress was not necessary.
3. A brace for the middle vault. There must be a continuous sheet of hard tissue extending from the nasal bones
down to the nostril margin to prevent the biologic force of wound contraction from notching the alar margin
upward. In the present case, the necessary brace of septal cartilage was left attached to the contralateral
septal flap as it hinged laterally. It could have been removed safely, carved, and replaced on the lining sleeve
in order to prevent collapse of the middle vault or upward contraction of the nostril rim.
4. An alar batten. Much as a thin strip of wood stiffens a sail, a thin, curved strip of cartilage stiffens the alar
margin against constriction, collapse, or upward notching. In the present case, a strip of chonchal wall
cartilage was carved to resemble the convex alar lobule subunit and was fastened along the lower edge of the
lining sleeve from the alar base to the apex of the new nostril.
When complete, the bone and cartilage scaffold of the nose enveloped the mucosal lining sleeve, stood erect by
itself, felt
rigid to the touch, and had the external shape of a normal nose, although it was somewhat smaller (Fig. 55.5). An
axial paramedian forehead flap was designed to fit over the internal framework of the new nose like a tailor-made
garment. As described earlier in this chapter, the flap was thinned, depilated, and sutured into position. The
gaping upper one-third of the forehead donor site healed by biologic wound contraction over a 6-week period.
Twenty-one days after the nose was assembled, the pedicle was excised. Ten months later, a single operative
revision was done (Figs. 55.6 and 55.7; see Fig. 55.8 for result four months after secondary revision).

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FIGURE 55.5 A-D: The subsurface nasal architecture is complete. It is rigid and has the desired nasal shape
reduced in all dimensions by 2.5 mm. An exact-pattern axial forehead flap is incised on the forehead on the
inside of the methylene lines. The distal 2 cm of the flap are radically thinned and depilated. The upper one-third
of the donor site heals by biologic wound contraction.
SUMMARY
A reconstructed nose is nothing more than a lump of transplanted tissues. The contoured surface of the
lump reflects lines and patches of light and casts lines and patches of shadow. If a plastic surgeon respects
the principle of subunits, and is assured of proper contour by the creation of a modeled hard-tissue chassis
on thin, compliant, vascular lining, and anticipates the inexorable force of the myofibroblasts, and is guided
by careful measurement and a good eye, he or she can cause this modeled lump of transplanted tissues to
impart from the outset the visual impression of a nose.
FIGURE 55.6 A-E: Ten months after pedicle division, a secondary revision was done. The nostril margin
was thinned by excising a wedge of fibrofatty tissue. No skin should be excised unless the alar margin is to
be elevated. (From Burget, ref. 8, with permission.)

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FIGURE 55.7 A-D: At the revisionary operation, the forehead flap tissue was elevated and the underlying
fibrofatty layer was shaped by excising thin strips of tissue. Loosely tied mattress sutures were employed to
hold the flap in its contoured bed. (From Burget, ref. 8, with permission.)

FIGURE 55.8 A-D: Final photographs taken 4 months after the secondary revision and 15 months after the
nose was assembled. The patient wears no makeup on her nose.
References
1. McCarthy JG, Lorenc ZP, Cutting C, et al. The median forehead flap revisited: the blood supply. Plast
Reconstr Surg 1985;76:866.
2. Millard DR. Preface to Aesthetic aspects of reconstructive surgery. Clin Plast Surg 1981;8:164.
3. Garst WP. Personal communication, 1976.
4. Millard DR. Reconstructive rhinoplasty for the lower half of the nose. Plast Reconstr Surg 1974;5:33.
5. DeQuervain F. Veber partielle seitliche rhinoplastik. Zentrabl Chir 1902;29:297.
6. Peck G. Techniques in aesthetic rhinoplasty. New York: Gower, 1984; 153-163.
7. Millard DRM. Numerous personal communications, 1969-1977.
8. Burget GC. Aesthetic restoration of the nose. Clin Plast Surg 1985;12:463.

(Trang không có chữ)

Chapter 56
Scalping Forehead Flap
J. G. McCARTHY
EDITORIAL COMMENT
This is one of the best techniques for total nasal reconstruction. The editors caution the surgeon to have all
preliminary reconstructions completed, so that the only defect left to reconstruct is the nose itself. The skin-
grafted defect left in the forehead may be eliminated with tissue expansion of the forehead at a later time.
The scalping forehead flap, described by Converse in 1942 (1, 2), represents the logical extension of the
classical (Indian) forehead flap in nasal reconstruction. This flap satisfies requirements for length and, in
addition, delivers a large area of forehead skin of satisfactory color and texture match for nasal reconstruction.
INDICATIONS
The scalping flap is a reliable technique for reconstructing large nasal defects. The flap skin is supple
enough to be folded to recreate the lobular portion of the nose. The flap design provides the desired length
for reconstruction of the columella, and the reconstructed nose thus has adequate size and projection.
The main disadvantage of this flap is the residual forehead donor defect. This is easily camouflaged in
females, however, by an appropriate hairstyle. The skin graft can be reduced in size by serial excision or by
replacement with local skin transferred either as a Schimmelbusch (3) or Juri (4) flap.
ANATOMY
The forehead scalping flap includes the forehead skin, the scalp and galea, and a major portion of the
vasculature of the forehead and anterior portion of the scalp.
The frontalis muscle, the galea, and their overlying integument are vascularized by an extensive anastomotic
network from the supraorbital, supratrochlear, and superficial temporal vessels (Fig. 56.1). All these vessels, with
the exception of the superficial temporal system on the ipsilateral side of the flap, ensure a rich blood supply to
the flap.
The venous drainage is remarkably efficient. The supraorbital veins, which run superficial to the frontalis muscle,
communicate with the anterior branch of the superficial temporal vein. The superficial temporal vein drains the
upper portion of the flap into the posterior facial vein. The supraorbital vein joins with the supratrochlear vein at
the medial angle of the orbit to form the angular vein.
The frontalis muscle, which is not included in the flap (see Fig. 56.5), is a thin quadrilateral muscle intimately
adherent to the superficial fascia. Its vertically oriented fibers are pale in color. The medial margins, joined above
the root of the nose, gradually diverge from each other, leaving a muscular gap in the central portion of the
forehead.
FLAP DESIGN AND DIMENSIONS
In planning the procedure, the surgeon must first define the nature and extent of the nasal defect to be

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resurfaced by the
flap. A wool or flannel cloth pattern of the defect is made and transferred to the lateral aspect of the selected side
of the forehead. In the male with a receding hairline, the donor area on the forehead should be positioned as far
laterally as possible to camouflage the donor site when the patient's full face is observed.
FIGURE 56.1 Blood supply of the forehead. Most forehead flaps are axial-pattern flaps based on the superficial
temporal, supraorbital, and supratrochlear vessels. (From Converse, ref. 8, with permission.)
FIGURE 56.2 Reduction of the residual nasal stump prior to subtotal nasal reconstruction. If the nose was large
prior to amputation (A), it is advantageous to reduce the projection of the residual stump (B) to facilitate nasal
reconstruction (C). (From Converse, ref. 8, with permission.)
It must be emphasized that if the residual stump is that of a large nose, its size should be reduced, because it is
technically simpler to build a smaller nose than a large one (Fig. 56.2). When the lobular portion of the nose,
including the columella and alar rims, is to be replaced, the distal end of the flap is folded on itself (see Fig.
56.10). Consequently, the working portion of the flap should be of sufficient size to allow such a degree of flap
fashioning.

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FIGURE 56.3 To reconstruct the tip of the nose, columella, and alae, the flap must be sufficiently long to reach
the lower lip prior to insetting. (From Converse and McCarthy, ref. 2, with permission.)
While the shape of the pattern had been roughly triangular in the past (narrower above than the wider distal
portion), a rectangular design has been employed in recent years.
When reconstructing the lobular portion of the nose, it is a good rule to be able to advance the flap to the lower
lip without tension in order to have a columella of adequate length and a nasal tip of sufficient projection (Fig.
56.3).
While the lining flaps maybe multiple in origin, the covering cutaneous flap should ideally restore the entire
aesthetic unit. In resurfacing the nose, the surgeon should strive to design the flap so that it extends from the
most distal portion of the nasal tip and the borders of the alae to the root of the nose. This is especially important
along the dorsum of the nose, where a transverse junction line (scar) between the flap and the dorsal skin is
obvious. The junction scars between a central flap and the adjacent lateral aspect of the nose (or cheek) are
less conspicuous.
Occasionally, it is necessary to resect the skin over the tip of the nose or a unilateral alar remnant in order to
reconstruct a satisfactory aesthetic unit. The distal end of the flap can be folded on itself to give a satisfactory
lobule and alar rim (usually after a secondary defatting procedure).
OPERATIVE TECHNIQUE
First Stage
An outline in ink should extend approximately 2 mm beyond the border of the pattern to allow for slight shrinkage
of the detached flap. The forehead or donor portion of the incision extends through the skin and subcutaneous
tissues, sparing the frontalis muscle (Fig. 56.4).
A plane of dissection is established between the light-colored fibers of the frontalis muscle and the donor
forehead skin (Fig. 56.5). Avoidance of a local anesthetic solution with epinephrine is helpful, since the solution
tends to blanch the underlying muscle and make its identification more difficult. It is imperative that the frontalis
muscle not be raised with the flap, since its preservation on the forehead provides expressive movements to the
skin graft and gives more satisfactory donor-site contour.
When the area of junction with the frontalis muscle and the galea is reached, the latter is incised and the
remainder of

the flap is raised along the plane between the galea and the pericranium (Fig. 56.5).
FIGURE 56.4 The scalping forehead flap (1). A: The working portion of the flap represents forehead skin that is
elevated superficial to the frontalis muscle. Note that the incision within the scalp extends across the calvaria on
a line between both auricular helices. B: The carrier portion of the flap is elevated at the subgaleal level. C: The
flap is transferred to the nasal defect. D: The donor defect is resurfaced with a full-thickness skin graft, either at
the time of the initial procedure or at the second stage (division of flap). The pericranium is covered with a Telfa
dressing. (From Converse and McCarthy, ref. 2, with permission.)
The incision extends in a cephalic direction from the lateral border of the skin flap that has been dissected from
the frontalis muscle. The flap incision is continued posteriorly to the level of a line extending across the scalp
from the tip of one auricle to the apex of the contralateral helix (coronal incision; Fig. 56.4A). The incision is then
extended along this line and across the midline to a point usually at the superior pole of the opposite helix. In this
way, the incision preserves the contralateral superficial temporal vessels. Laterally, the temporal fascia is raised
with the flap. The dissection is carried caudally to a point above the nasofrontal angle medially and the
supraorbital arches laterally, care being taken to preserve the supratrochlear and supraorbital vessels, as well as
the supraorbital nerve (Fig. 56.4C). A large flap that can be folded on itself without tension or twisting is raised.

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FIGURE 56.5 The working portion of the flap (forehead skin) is elevated superficial to the frontalis muscle
(arrows). The carrier portion is raised at a deeper level (deep to the galea).
It has been my experience that the larger the scalp portion of the flap, the easier is its return to the original site
over the calvaria. Once the flap pedicle is folded on itself, it requires
little postoperative care. A small raw area between the flap and its attachment to the nose can be covered by a
dressing or a small upturned flap from the root of the nose. This area requires cleaning with a cotton-tipped
applicator whether it is left uncovered or is resurfaced with a small flap.
FIGURE 56.6 The second stage (division of the flap). A: The temporary dressing (Telfa, skin allograft, or porcine
xenograft) is removed after the flap has been divided at the appropriate level at the root of the nose. B: The flap
is then unfolded by simple incising. C: The flap is then distended to its former size. D,E: The flap is returned and
sutured to the posterior scalp border. (From Converse, ref. 8, with permission.)
The donor defect is resurfaced with a full-thickness skin graft, which is taken either from the postauricular region
or from the supraclavicular area if the defect is large. The quality of the healed skin graft is superior when the
grafting technique is deferred until the second stage.
Second Stage (Flap Division)
The flap is usually divided and returned to the calvaria between the fourteenth and eighteenth days (Fig. 56.6),
unless the nasal recipient site is poorly vascularized, such as after radiotherapy. Further delay renders the task
of approximating the margins of the flaps to the edge of the coronal incision a difficult one.
At the time of division and final inset of the flap, it is essential that the pedicle be divided at a level that will leave
sufficient flap tissue to resurface the more cephalic portion of the nasal defect.
Secondary Defatting Procedures (Fig. 56.7)
Earlier attempts at nasal reconstruction resulted in noses that were smaller in volume than desired, because
adequate nasal lining had not been provided. With the passage of time, there was a shrinkage of the

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reconstructed nose. In his 1920 text (5), Gillies stated: “The author had recognized that all noses must be skin
lined, but on digesting Keegan's written work, one was absolutely convinced that this was the right principle” (6,
7).
A common mistake in the past had been to line a forehead flap with a skin graft in order to furnish a lining, as in
subtotal nasal reconstruction. The skin graft caused stiffness of the flap and difficulty in adapting the flap to the
shape of the nose. Another major disadvantage was the technical difficulty in finding a surgical plane of cleavage
between the flap and skin graft in order to insert a bone or cartilage graft for skeletal support in subtotal nasal
reconstruction.
Lining should therefore be provided by flaps—preferably local turnover flaps (Fig. 56.8). If the latter are not
available, a median forehead flap with a subcutaneous pedicle is an alternative method of providing lining (Fig.
56.9). Infolding of the distal aspect of the flap provides a nasal tip and columella with vestibular lining (Fig.
56.10).
I prefer to reconstruct the nose by first restoring cutaneous coverage and lining, waiting until postoperative
edema has subsided, and furnishing skeletal support at a later stage. In many situations (especially smaller
defects), there is no need for skeletal support. If the bony structures (platform) in the root of the nose are
present, cantilever bone grafting is the method of choice (Fig. 56.11). However, if the bony platform has been
destroyed, a cartilage graft removed from the core of a costal cartilage is the preferred technique for achieving
nasal skeletal support.
SUMMARY
The scalping flap is a reliable technique for providing a relatively large area of forehead skin of satisfactory
color, texture, and thickness for resurfacing nasal defects.
FIGURE 56.7 A-C: A major portion of the flap can be incised and elevated, and the undersurface defatted,
in order to give a more sculpted appearance to the nose. (From Converse, ref. 8, with permission.)

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FIGURE 56.8 Local turnover flaps for nasal lining. A: Outline of flaps. B: Following elevation, closure is
accomplished with absorbable sutures.
FIGURE 56.9 Reconstruction of a full-thickness defect of the nose by a combination of a scalping flap and
an island forehead flap. A: Respective positions of the forehead flaps, which will provide the covering and
the lining tissue. B: The island flap is raised on a subcutaneous pedicle. Mucous membrane from the
septum provides lining tissue over the left nasal fossa. C: The island flap furnishes the lining for the
remainder of the defect. D: The scalping flap transfer is being completed. (From Converse, ref. 9, with
permission.)

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FIGURE 56.10 Reconstruction of the nasal tip, columella, and alar rims with the distal portion of the
scalping forehead flap. A: A suture (a) is inserted in the distal portion of the flap. B: The suture (a) is then
placed through a more proximal portion of the undersurface of the flap. C-E: In this way, the nasal tip,
columella, and alar rims are reconstructed. (From Converse, ref. 10, with permission.)
FIGURE 56.11 Cantilever insert bone graft (ilium) maintained by wire fixation to the bony stump.
References
1. Converse JM. New forehead flap for nasal reconstruction. Proc R Soc Med 1942;35:811.

2. Converse JM, McCarthy JG. The scalping forehead flap revisited. Clin Plast Surg 1981;8:413.
3. Schimmelbusch C. Ein neues verfahren der rhinoplastik und operation der sattelnase. Verh Dtsch Ges
Chir 1895;24:342.
4. Juri J, Juri C, Cerisola J. Contribution to Converse's flap for nasal reconstruction. Plast Reconstr Surg
1982;69:697.
5. Gillies HD. Plastic surgery of the face. London: Oxford University Press, 1920.
6. Gillies HD. The development and scope of plastic surgery. Northwest Univ Bull 1935;35:1.
7. Keegan DR. Rhinoplastic operations, with a description of recent improvements in the Indian method.
Paris: J. Baillere, 1900.
8. Converse JM, ed. Reconstructive plastic surgery, 2nd ed. Philadelphia: Saunders, 1977.
9. Converse JM. Clinical applications of the scalping flap in reconstructive surgery of the nose. Plast
Reconstr Surg 1969;43:247.
10. Converse JM. Reconstruction of the nose by the scalping technique. Surg Clin North Am 1959;39:335.

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Chapter 57
Retroauricular-Temporal Flap
H. WASHIO
V. C. GIAMPAPA
The retroauricular-temporal flap can be used to transfer tissues from behind the ear for reconstruction of limited
defects of the nose, forehead, cheek, and lower eyelid (1, 2).
INDICATIONS
Available donor tissue should be carefully weighed against the size of the defect. The procedure is not
recommended for patients with known vascular problems, such as arteriosclerosis, hypertension, or
uncontrolled diabetes. It is also not indicated for elderly or obese patients. Two retroauricular-temporal flaps
can be elevated at the same time. This flap also can be used in conjunction with other local flaps, such as a
forehead flap.
ANATOMY
There are ample anastomoses between the superficial temporal artery and the retroauricular (postauricular)
artery (Fig. 57.1A). By incorporating these two vessel systems in a temporal scalp flap, a flap has been designed
that can be elevated without delay.
FLAP DESIGN AND DIMENSIONS
The superficial temporal and retroauricular arteries are identified with a Doppler flowmeter. Selection of points A,
B, C, and D in Figure 57.1A is the key. Point A is the point around which the entire flap turns; it is a fixed point
just in front of the anterior end of the helix and behind the superficial temporal artery.
The next step is the selection of point C. For the flap to reach a defect, line AC must be approximately half the
length of the distance between point A and the defect. In an average-sized adult, the nose is about 14 cm away
from point A. This means that for nasal reconstruction, line AC will have to be approximately 7 cm in length. To
avoid injury to the superficial temporal artery and also to facilitate effective design of the flap, line AC is directed
10° to 15° posteriorly from an imaginary vertical line drawn through point A.
The selection of point B is important, since line AB forms the base of the pedicle. The length of line AB should be
about 8 cm, and angle CAB should be about 60°. Ordinarily, one can select this point near to or at the hairline.
Obviously, this is not possible in an individual who is bald or has a receding hairline.
Point D is marked in such a way that the two triangles ABC and DBC are symmetrical (Fig. 57.1A and B) and
form a rhombus ABDC. The advantage of having this rhombus is that the raw surfaces of the two triangles will
rest on each other when the flap is transferred, thus eliminating this raw surface (Fig. 57.1C).
The margin for the rest of the flap is drawn in a curve from point D in order to include the retroauricular vessels
and the postauricular skin (Fig. 57.1A).
OPERATIVE TECHNIQUE
The outer incision of the flap is made first. It is essential to include the galea aponeurotica in the flap. Then the

postauricular skin is incised and elevated. The central cut AC is made last under direct vision. Major branches of
the artery can be identified easily by looking through the translucent galea from underneath (Fig. 57.1B).
FIGURE 57.1 A: Relationship between the retroauricular and temporal vessels along with the position of key
points in the flap. B: Elevation of the flap. The central cut AC should be made last while looking directly at the
major vessels through the galea on the underside of the flap. C: The raw surfaces are covered with a split-
thickness skin graft. The two triangles ABC and DBC will fold onto each other. D: Transfer of the flap.
Hemostasis is accomplished by electrocoagulation and direct suture. The raw surfaces of the flap donor site and
the flap are covered by split-thickness skin grafts (Figs. 57.1C and 57.2D).
The next step is preparation of the recipient area. This is the time to add additional structural support or to
rearrange the tissues of the recipient area. Any attempt to do this after the flap has been transferred is not
recommended. The flap is then transferred and sutured securely in place (Fig. 57.2D). The thickness of the flap
will allow sharp bending along lines AB and BC without compromising the circulation. However, any undue
tension on the flap must be avoided. Elevation and transfer of the flap are carried out in one stage.
The flap is divided between 7 and 14 days, depending on the size of the raw surface of the recipient site. The
carrier portion of the flap is then returned to its donor area.
CLINICAL RESULTS
There was one tip necrosis in a series of 16 patients. This was believed to be due to arterial spasm
subsequent to an attempted arteriogram. There was one case of infection of the scalp after the flap was
returned to the donor site.
SUMMARY

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The retroauricular temporal flap can be used without a delay to reconstruct areas of the face using the skin
and cartilage from behind the ear.
FIGURE 57.2 A: A 26-year-old woman with a right alar defect following radiation of a hemangioma in
infancy. There was extensive scarring of the adjacent tissues. B: Design of the flap. C: A portion of conchal
cartilage and postauricular skin is incorporated in the flap. D: The raw surfaces are grafted, and the two
triangles of the flap fold onto each other. E: Appearance of the flap at 2 weeks, just before division. F: Nine
months postoperatively. (From Washio, ref. 1, with permission.)
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.

(Trang không có chữ)

Chapter 58
Temporoparietal Fascial Flap for Nasal Reconstruction
G. H. SASAKI
EDITORIAL COMMENT
This chapter presents another source of tissue for reconstruction of the ala nasi. Obviously, it is not a first
or second choice. If used at all, it would be most applicable for patients with male pattern baldness.
An axial subcutaneous fascial flap based on the superficial temporal vessel and its major branches has provided
an alternative method for reconstruction of full-thickness defects of the ear and anterior upper half of the face (1,
2, 3). The development and use of this flap for nasal reconstruction are logical extensions of its potential.
Stimulated by Corso's demonstration (4) of a paucity of venous drainage within the terminal areas of arterial
branching, I have modified the design of the axial subcutaneous fascial flap to achieve both a longer pedicle and
improved viability.
INDICATIONS
Nasal defects can often be reconstructed from local tissue sources. However, further experience will
determine the reliability and applicability of the temporoparietal fascial flap for these defects. Advantages of
this flap include (1) transposition of a well-vascularized, thin, and pliable flap that accepts grafts on either
side as needed, (2) reconstruction in a single stage, and (3) transposition of tissue outside the area of
trauma, radiation, or tumor.
Potential difficulties with this flap are (1) variability in vascular distribution, (2) paucity of venous drainage,
(3) inadequate pedicle length, and (4) loss of hair at the donor site.
ANATOMY
From injected cadaver dissections, the temporoparietal fascia appears to represent a distinct, separate layer
superficial to both the fascia of the temporalis muscle and the contiguous galea aponeurotic extensions superior
to the crest of the temporal fossa. At the level of the condylar process of the mandible, the superficial temporal
artery passes between the mandibular condyle and the external auditory canal and then insinuates over the
zygomatic arch to lie on the temporoparietal fascia. Within the confines of anatomic variation, the main superficial
temporal artery divides at the level of the apex of the ear into its frontal and parietal branches. Further cephalad,
the parietal segment generally divides into two or three terminal branches (Fig. 58.1).
In injected and noninjected specimens, the main superficial temporal artery and its frontal and parietal branches
can be visualized easily from the level of the tragus to about 12 cm in a cephalad direction. At about 14 cm, the
terminal branches of the parietal segment take a more superficial route, blending into the subdermal plexus.
Further dissection to create a vascularized paddle of subcutaneous fascia may be unsafe unless deep dermis is
incorporated into the fascial flap. Venous collaterals coursing parallel with the arteries or within the arterial
domain of the flap can be identified easily.
FLAP DESIGN AND DIMENSIONS