Grabb’s Encyclopedia of Flaps Head and Neck

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FIGURE 58.2 Schematic depiction of the axial subcutaneous fascial flap, indicating the axis of rotation, the
unsafe zone of dissection, and the distal dermal segment, with the potential for incorporation of a skin paddle in
the design.
The temporoparietal fascia is now divided at the level of the tragus on each side of the pedicle, which is at least
2.5 cm across. The fascial flap is then elevated with relative ease off the anterior fascia of the temporalis muscle
and more cephalad, superficial to the pericranial tissues and deep to the galea aponeurotica (Fig. 58.3). Every
attempt must be made to incorporate as many venous channels as possible within the flap to facilitate drainage.
After a large subcutaneous tunnel at the axis of the flap is created to the nasal defect, the flap is passed
unhindered and may be lined or covered with simple or composite grafts as needed. Alternatively, the flap paddle
may be prelined with grafts 4 to 6 weeks prior to transfer. The donor wound is approximated primarily over
closed suction drainage.
CLINICAL RESULTS
The temporoparietal fascial flap has been used in four patients with nasal defects of durations ranging from
2 months to 2 years. The vascularized fascial flap has provided stable coverage, allowing a suitable graft
for cover or lining (with or without cartilaginous support) to suit the defect.
The full-thickness nasal deformities included one subtotal nasal loss and three partial lobular defects.
Immediate skin grafting for cover and lining was performed in three patients, while the remaining patient is
shown in Figure 58.4 In this patient, a 5-mm rim of ischemia was noted at the reconstructed
alar margin, but it resulted in no loss of tissue or exposed cartilage.

FIGURE 58.3 Schematic drawing of the flap elevation off the anterior fascia of the temporalis muscle and,
more cephalad, the pericranial tissue deep to the galea aponeurotica.
FIGURE 58.4 A: A 2.5 × 3.0 cm defect after full-thickness resection of the reconstructed ala and entire
cartilaginous septum and partial excision of the ipsilateral primary palate and upper lip for persistent basal
cell carcinoma. A forehead flap had been used in a previous reconstruction, and another basal cell
carcinoma had been removed in the area of the right nasolabial fold. A conchal-cutaneous graft from the ear
was allowed to mature for 6 weeks under a skin paddle in a bald spot based on the parietal branch of the
superficial temporal artery. B: Reconstruction at 1 year postoperatively using prelined conchal-cutaneous
ear graft transposed on the fascial flap through a subcutaneous pocket. Arrows indicate the cephalad
border of the conchal graft under the skin paddle taken from a bald spot.
Moderate hair loss was noted at the donor site in two of three patients, but this presented no significant
cosmetic problem. Sensation to the ear was preserved in all patients.
SUMMARY
Partial nasal reconstruction can be accomplished in a single stage using the temporoparietal fascial flap.

References
1. Tegtmeier RE, Gooding RA. The use of a fascial flap in ear reconstruction. Plast Reconstr Surg
1977;60:406.
2. Byrd HS. The use of subcutaneous axial fascial flaps in reconstruction of the head. Ann Plast Surg
1980;4:191.
3. Kernahan DA, Littlewood AHM. Experience in the use of arterial flaps about the face. Plast Reconstr Surg
1961;28:207.
4. Corso PF. Variations of the arterial, venous, and capillary circulation of the soft tissues of the head by
decades as demonstrated by methyl methacrylate injection technique, and their application to the
construction of flaps and pedicles. Plast Reconstr Surg 1961;27: 160.

Chapter 59
Reversed Superficial Temporal Artery Postauricular Compound
Skin and Cartilage Flap
M. ORTICOCHEA
EDITORIAL COMMENT
The principle of reversal of flood described in this chapter, both arterial and venous, has taken on
considerable importance over the past several years, both in this and other sites of the body. The
innovative technique of nasal reconstruction is a relatively complicated one, and the goal might be achieved
more simply with some of the other techniques described.
The three anatomic structures of skin coverage, nasal framework, and nasal lining can be found in the external
ear. The retroauricular skin and that of the mastoid region will cover the nasal surface. The conchal cartilage
and, occasionally, a long, thin portion of the mastoid and temporal bone will provide the framework. The thin skin
firmly adhering to and covering the lateral surface of the cartilage of the conchal cavity will form the internal lining
of the reconstructed nose.
INDICATIONS
Bilateral reversed superficial temporal artery postauricular compound skin and cartilage flaps can be used
for total nasal reconstruction (1, 2, 3, 4). The advantages are that coverage, lining, and framework can be
provided at the same time. The skin is the same color, texture, and thickness as that of a normal nose. The
patient can breathe normally, since the nostrils are of a good size.
The ears from which the conchae have been removed keep their normal shape, size, and appearance and
are only slightly flatter than normal. Replacement of the concha by a skin graft does not change its cosmetic
appearance.
ANATOMY
The technique depends on the transfer of each concha on a flap with its base on the temple and including the
superficial temporal vessels. To make this feasible, the natural flow of blood in these vessels must be reversed.
This is accomplished by dividing the vessels in front of the ear and transplanting the cut end into the substance
of the flap behind the ear (see Fig. 59.4). The retrograde blood supply then comes from the natural anastomoses
with the branches of the ophthalmic vessels in the lateral forehead (supraorbital, supratrochlear, and lacrimal).
This principle of reversal of blood flow is applicable to many flaps in facial and body reconstruction and makes
new flap designs possible.
FLAP DESIGN AND DIMENSIONS
The flap base must be fairly high in the frontal area to ensure sufficient flap length. Otherwise, there may be
difficulty in bringing the concha far enough to reconstruct the alae, nostrils, and columella. Vascular impairment
of the upper pole of the remaining portion of the ear may occur if the crus of the helix pedicle is too narrow. It is
important to include all the skin adjacent to the triangular fossa with the pedicle. Postoperative edema of the

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reconstructed nose may persist for some months, but later resolves. Tissue contraction occurs postoperatively at
all stages. For this reason, all the postauricular skin is included in the flap. Hairy skin, however, is avoided.
OPERATIVE TECHNIQUE
Total nasal reconstruction using this technique requires four stages:
1. The flaps are delayed on each side of the head.
2. The lower pedicle of each flap is delayed (see Fig. 59.6).
3. The auricular ends of the flaps are sutured to their new site in the nasal region (see Fig. 59.7).
4. The carrier pedicles are returned to their donor sites, and any revisions of the new nose are carried out (see
Fig. 59.8).
FIGURE 59.1 A: The flap is 4 cm wide and it overlies the superficial temporal vessels. The preauricular incision
allows exposure of the vessels, which are ligated at the level of the tragus and subsequently transplanted
beneath the flap. B: On the posterior ear, the incision is made 1 cm from the helical rim. (From Orticochea, ref. 4,
with permission.)
Stage 1
The patient is placed in the Trendelenburg position to engorge the superficial temporal vessels, and the flaps
that overlie these vessels are marked. Each flap measures 4 × 12 cm (Figs. 59.1 and 59.2). The patient is
returned to the Fowler position before the flaps are incised.
The frontal portion of the flap is dissected at the level of the loose areolar tissue between the galea aponeurotica
and the pericranium. The posterior branch of the superficial temporal vessels and other collaterals are sectioned
and tied (Fig. 59.1).
The auricular portion of the flap includes the full thickness of the concha. The preauricular skin and the cartilage
are sectioned along the anterior, superior, and posterior borders of the concha. A small inferior pedicle (2 cm
wide) should be left intact to ensure a blood supply to the thin preauricular skin (Fig. 59.3). On the medial aspect
of the ear, the lower incision continues parallel to the helix and about 1 cm from the rim of the ear as far as the
retroauricular groove. The upper incision is carried along the hairline to the lower margin of the mastoid process
(Fig. 59.2). The posterior incision limiting this flap should reach the level of the earlobe in its lower end.
A 4-cm-wide pedicle over the mastoid is retained to ensure the blood supply of the medial auricular skin, for at
this stage the supply still comes from below and not from above. It will be noted that the flap includes all the skin
covering the medial aspect of the concha plus the glabrous skin over the temporal bone and the mastoid process
(Fig. 59.2). When separating this skin from the underlying structures, the posterior auricular vessels are divided.
The skin of the mastoid region and that of the upper end of the sternocleidomastoid region should be raised to
improve their blood supply. This procedure will ensure cutaneous vascular continuity. At this stage, a strip of
cortex from the temporal and mastoid bones may be included in the flap for support of the nasal skeleton.

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FIGURE 59.2 The incision marking the posterior limit of the fronto-auricular flap should extend to the level of the
lower end of the earlobe (M). (From Orticochea, ref. 4, with permission.)
Transplantation of the Superficial Temporal Vessels
The thin skin at the upper end of the postauricular sulcus, which connects the auricular portion of the flap to the
scalp pedicle, has few blood vessels and constitutes a vascular barrier (M in Fig. 59.4B; also see 2 in Fig. 59.6).
Transplantation of the superficial temporal vessels is essential to overcome this barrier and to ensure adequate
blood supply to the auricular end of the flap.
FIGURE 59.3 Diagram of the incision on the lateral surface of the ear. The preauricular skin and cartilage are
divided as shown. Three vascular bridges are retained (arrows); the skin covering the concha is supplied
through that marked 3, while the remainder of the ear is nourished by the pedicles at the crus of the helix and at
the lobule. (From Orticochea, ref. 1, with permission.)

FIGURE 59.4 A: The flap is partly raised. The superficial temporal vessels (1) are dissected in such a way that a
cuff of subcutaneous tissue remains around them. Note the hemostats on the cut end of the vessels. B: The
region M has few blood vessels and constitutes a vascular barrier, which is by-passed by transposing the
vessels to the point +. (From Orticochea, ref. 3, with permission.)
Through a vertical preauricular incision 1.5 cm in front of the ear, the superficial temporal vessels are dissected
free, with the fatty tissue surrounding them retained. They are ligated at the level of the lower border of the
tragus (Figs. 59.4 and 59.5). A tunnel is then made with scissors through the substance of the flap at the upper
end of the concha, and the divided vessels are passed through and sutured to the posterior border of the flap.
The raw undersurface of the carrier portion of the flap above the ear is covered with a split-thickness skin graft.
Finally, the flap donor area is resurfaced with a split-thickness skin graft. This graft covers the pericranium of the
frontal bone, the temporal fascia, the musculoskeletal surface of the temporal bone and mastoid process, and the
site where the concha was in contact with the bone. The same procedure is carried out on each side of the
head.
Stage 2
Before transplantation of the lower end of the frontoauricular flap (containing preauricular and retroauricular skin,
conchal cartilage, and temporal bone) to the nasal region, the delay of the lower pedicle of the flap is carried out
(Fig. 59.6). This delay will avoid vascular insufficiency by sectioning the skin between the two vertical incisions
and raising the lower end of the flap.
FIGURE 59.5 A,B: The reversed superficial temporal artery compound skin and cartilage flap before it is moved.
(From Orticochea, ref. 4, with permission.)

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Stage 3
The auricular end of each flap is detached from the inferior skin attachment of the concha. The flaps are then
sutured in place to the lateral borders of the nasal defect and to each other in the midline (Fig. 59.7). A two-layer
closure of both lining and skin is made in each case, but the cartilage is not sutured. Finally, the remaining
portion of the ear is returned to its normal position and sutured to the neighboring tissues.
Stage 4
The pedicle of the flap is divided at the desired level in the nasal region. When this is done and the lower ends of
the superficial temporal vessels are divided, an abundant flow of blood from the artery results, thus
demonstrating that reversal of flow has been achieved. The pedicles are returned to their donor site, and the
necessary trimming of the nasal flaps is carried out (Fig. 59.8).
FIGURE 59.6 The final delay. An incision (ab) joins the lower ends of the vertical incisions. The lower end of the
flap (1) is raised as far as the narrow zone (2) before being resutured to its original site. The blood supply from
the transposed superficial temporal artery through the narrow zone is sufficient to nourish the flap. (From
Orticochea, ref. 4, with permission.)
FIGURE 59.7 The flaps have been moved to the nose. The donor areas and the underside of the carrier portion
of the flaps have been skin grafted. (From Orticochea, ref. 3, with permission.)

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FIGURE 59.8 A-E: Final result. The nose and ears have a normal shape. The columella and the size of the
nostril openings are normal. (From Orticochea, ref. 4, with permission.)
SUMMARY
Bilateral reversed superficial temporal artery postauricular compound skin and cartilage flaps can be used
for total nasal reconstruction. The flaps are transferred on long pedicles based on each temple, and the
success of the operation depends on two biological phenomena: (1) the ability of the blood flow in the
superficial temporal vessels to be reversed, and (2) the revascularization of the inferior part of the flap
(normally supplied by the postauricular vessels) by the reversed flow in the superficial temporal vessels.
References
1. Orticochea M. A new method for total reconstruction of the nose: the ears as donor areas. Br J Plast Surg
1971;24:225.
2. Orticochea M. Méthode pour la reconstruction totale du nez. Ann Chir Plast 1977;22:181.
3. Orticochea M. Refined technique for reconstructing the whole nose with the conchas of the ears. Br J
Plast Surg 1980;33:68.
4. Orticochea M. A new method for total reconstruction of the nose: the ears as donor areas. Clin Plast Surg
1981;8:481.

Chapter 60
Cervical and Clavicular Tubed Skin Flaps
B. C. MENDELSON
J. K. MASSON
These flaps are predominantly of historical significance (1). The current management of skin malignancies
occurs earlier and is more appropriate and the indications for radiotherapy are stricter than in the past. These
facts have dramatically reduced the need for nasal reconstructions. During the years when major nasal
reconstruction was more common, clavicular and cervical tubed pedicle flaps were used frequently. That era
corresponded to the time in which tubed pedicle flaps were in general use by plastic surgeons.
INDICATIONS
Both cervical and clavicular tubed skin flaps provide skin of quite good color match with facial skin (second
only to that of forehead flaps), but the texture is softer and finer than either forehead or nasal skin.
In general, forehead flaps provide the best nasal reconstructions (2), but where such flaps are prohibited
because of preexisting scarring or extensive facial radiation, the healthy tissue provided by distant flaps
may be required (3).
The major advantage of these distant flaps over forehead flaps is the avoidance of further facial scarring.
The clavicular flap, unlike the cervical flap, has the advantage of not leaving any visible scarring when the
patient is clothed (4).
Because these flaps require initial attachment to the nasal bridge, there is some difficulty in molding the
details of columella and nostrils satisfactorily when the distal end is later transected (5). Accordingly, their
best use is for coverage. The clavicular flap, without the size limitation of forehead or cervical flaps, can
provide sufficient tissue for much larger defects extending onto the adjacent cheek and lip.
The major limitation of these flaps is the need for multiple operations and a long time for completion. While
some of the cervical flaps can reach directly to the nose, most of these distant flaps have insufficient reach
and require migration via an intermediate attachment, with several weeks extra preparation time (6). There
is a real risk of major complications in the use of these, as well as other, tubed pedicle flaps.
Both flaps are contraindicated in the presence of heavy scarring of the skin of the neck or clavicular region.
In males, a heavy growth of hair in these regions is also a contraindication.
ANATOMY
Both these flaps are based on a random pattern of circulation.
FLAP DESIGN AND DIMENSIONS
Clavicular Tubed Flap
The flap is usually designed parallel to and just below the clavicle (7). Its dimensions are determined by the size
of the nasal defect and the distance to the nose. Traditional teaching strongly advises a maximum length-breadth
ratio of 3:1 (6).
At least four surgical procedures are necessary for transfer of one end of the clavicular tube to the nose.
Previously, either end of the flap was used for nasal coverage, but it is now known that the acromial skin of the

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lateral end can be safely transferred to the nose without delay, carried on the medially based deltopectoral flap
(see Chapter 127).
The only use of this flap at present is when the skin of the medial end of the flap in the sternoclavicular joint
region is preferred over the lateral skin. Since it is not usually possible for the flap to reach the nose directly, the
lateral end is migrated by means of an intermediate stage on the neck (Fig. 60.1).
FIGURE 60.1 Clavicular tubed flap. A: Double-pedicle flap of skin is elevated over or just below clavicle and is
tubed. A delay of the lateral end is performed 4 weeks later. B: Three weeks later, the lateral end is migrated via
an intermediate attachment to the neck. One or two delay operations on the medial end are performed. C: Three
weeks after its delay, the medial end is transposed to the cephalad end of the defect. Three weeks later, the
unused portion is discarded. (From New and Erich, ref. 4, with permission.)
Cervical Tubed Flap
Cervical flaps can be used in several different ways. Small nasal defects (e.g., heminasal, columella) can be
corrected using a narrow tubed cervical flap. The flap can be created in the line of the neck skin folds, and the
upper end (postauricular skin) can be used for the definitive repair (2).
A larger area of skin is obtained by the more obliquely placed cervical flap (Fig. 60.2). The pedicle essentially
parallels the sternomastoid muscle and carries the paddle of skin situated over the lower neck sternoclavicular
joint region. The traditional operation, performed as a tube pedicle, was, by definition, a multistaged procedure. It
is now recognized that the same paddle of skin can be carried to the nose using the sternomastoid muscle as the
carrier pedicle, i.e., the sternomastoid musculocutaneous flap (see Chapter 194). Since this is a two-stage
procedure, with the reduced risk associated with an axial-pattern flap, there is no current indication for using the
oblique cervical flap.
If the neck skin itself is used for the repair, the flap must be situated low on the neck, especially in men, to avoid
hair-bearing skin. As a consequence, the flap is too short for direct reach to the defect, and migration by means
of an intermediate attachment is required (Fig. 60.3). The nasolabial region is a more comfortable temporary
attachment for the patient than the mucosa of the lower lip.
The transverse cervical flap is usually 15 × 4 cm (8).

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FIGURE 60.2 Oblique cervical tubed flap. A: The tubed pedicle is formed obliquely parallel to the sternomastoid
muscle. B: The distal end is transposed to a partial nasal defect. C: The residual flap is finally detached and
inset after previous partial severance of the pedicle.
OPERATIVE TECHNIQUE
Clavicular Tubed Flap
At the first stage of the operation, the pedicle is tubed in the traditional manner (4). At the second operation some
4 weeks later, a delay of the lateral end of the flap is performed, and 3 weeks later, the lateral end is attached to
the neck.
One or even two delay operations on the medial end, 4 weeks apart, are advised (especially if the nasal recipient
bed has been radiated) before finally attaching the medial end to the nasal defect.
Three weeks later, the final inset is performed, and the residual pedicle is either discarded (if not required) or
else the neck attachment is brought onto the face for further coverage (Fig. 60.1). Usually several touch-up
procedures are subsequently necessary.
Cervical Tubed Flap
The skin flap is tubed, and the donor wound edges are undermined and approximated behind the bipedicle.
Three weeks later, a delay is performed on one end, and that end is transferred 3 weeks after the delay
procedure, usually to a temporary recipient site on the nasolabial fold.
FIGURE 60.3 Transverse cervical tubed flap. A: The tubed pedicle is formed transversely across the lower
neck. Delay of one end is performed 3 weeks later. B: The delayed end is transferred to the nasolabial region.
The neck end is delayed 3 weeks later. C: The neck end of the flap is transferred to a partial nasal defect.
Three weeks later, the remaining neck attachment is delayed, and a further 3 weeks later, the definitive transfer
to the nose is achieved.

Three weeks after that, the excess pedicle tissue is removed, and the final inset is performed. Usually, several
touch-up procedures are necessary.
CLINICAL RESULTS
Despite producing some excellent results, there has been a significant complication rate associated with
use of the clavicular flap. In a report on 56 clavicular tubed flaps from the Mayo Clinic (1) (only six of which
were for total nasal reconstruction), there was a median of six operations required (range 4 to 11) over a
median 4-month period for basic completion of the reconstruction. A median number of three touch-up
procedures was later performed.
The clavicular flap had the highest complication rate of the various flaps used. Eleven percent underwent a
major ischemic event, requiring debridement and later reattachment. In addition, 15% developed minor
necrosis and 17% had other minor complications.
SUMMARY
Clavicular and cervical tubed flaps have been described for use in nasal reconstruction. The clavicular flap
is best for nasal coverage, and the cervical flap is appropriate for smaller defects such as the columella.
However, advances in plastic surgical techniques, such as axial-pattern and musculocutaneous flaps, have
largely supplanted random-pattern tubed flaps.
References
1. Mendelson BC, Masson JK, Arnold PG, Erich JB. Flaps used for nasal reconstruction: a perspective
based on 100 cases. Mayo Clin Proc. 1979;54:91.
2. Young F. The repair of nasal losses. Surgery 1946;20:670.
3. Blocksma R, Innis CO. Reconstruction of the amputated nose: report on 30 cases. Plast Reconstr Surg
1955;51:390.
4. New GB, Erich JB, eds. The use of pedicle flaps of skin in plastic surgery of the head and neck.
Springfield, III.: Charles C Thomas, 1950.
5. Erich JB. Traumatic defects of the nose and cheeks. Surg Clin North Am 1949;29:1009.
6. Erich JB. A survey of skin grafts and pedicle flaps for repair of nasal defects. Ann Otol Rhinol Laryngol
1963;72:808.
7. Aymard JL. Nasal reconstruction. Lancet, 1917.
8. Paletta FX, Van Norman RT. Total reconstruction of the columella. Plast Reconstr Surg 1962;30:322.

Chapter 61
Upper Arm (Tagliacozzi) Skin Flap
B. C. MENDELSON
J. K. MASSON
EDITORIAL COMMENT
This is a classic plastic surgery flap; although it has been supplanted by a host of other options, the
advantage of having medial arm skin which is a reasonable color and texture match for this location still
remains. However, the use of a free flap is probably a preferable choice.
The Tagliacozzi flap serves as a symbol in the tradition of plastic surgery. Tagliacozzi's portrait is on the logo of
the American Board of Plastic Surgery, and his flap is centered in the emblem of the American Association of
Plastic Surgeons. The only major advance in the use of this flap since it was first reported by Gaspare
Tagliacozzi in 1597 (1, 2) has been the introduction of anesthesia. Several variations of this pedicled arm flap
have been described (3, 4, 5, 6, 7, 8).
INDICATIONS
In current practice, pedicle flaps from the arm have limited application in nasal reconstruction. The skin
color is often a poor match with facial skin, certainly less satisfactory than that of forehead and clavicular
skin flaps. The texture of the hairless skin of the anteromedial surface is too fine and the dermis too thin for
effective total nasal reconstruction without the provision of additional support at a subsequent operation.
The thinness of the skin, however, can be an advantage for coverage of an exposed nasal skeleton. The
immobilization required is a most trying position for the patient and can result in permanent stiffness of the
shoulder (9). The major advantage of the flap is that less time is required for a nasal reconstruction than
with any of the other distant pedicle flaps, e.g., clavicular. Also, further facial scarring associated with
forehead flaps can be avoided.
The Tagliacozzi flap is still the preferred flap in several situations (8). This flap should be used for total
nasal reconstruction in children, preserving the forehead for definitive rhinoplasty later in life. It is also
preferred for those in whom the forehead is not available, either because of a low hairline or because of the
unacceptable aesthetic result of a skin graft on the residual forehead donor site. This is a real factor in
darker-skinned patients (African-American, Latino, Indian), in whom hyperpigmentation of the graft is
anticipated.
ANATOMY
There is an arterial axis in the upper arm between the deltoid branches of the thoracoacromial artery and the
recurrent branches of the radial and ulnar arteries of the elbow (10). On this basis, the Tagliacozzi flap may be
partly an arterialized rather than a true random-pattern tubed pedicle flap. This may account for its good
vascularity compared to other distant pedicle flaps, e.g., clavicular. The classically located flap ignores the
adjacent arterialized skin of the lateral arm used in the cervicohumeral flap (see Chapter 134).

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FLAP DESIGN AND DIMENSIONS
The size of the flap, ultimately limited by the dimensions of the arm, depends on the size of the nasal defect, but
with allowance for subsequent shrinkage of 25%. Planning is done in reverse, locating and orienting the flap so
that it is sited adjacent to the nose when the arm is raised into position for immobilization.
An average flap is constructed with parallel incisions 15 cm long and about 8 cm apart on the anteromedial
aspect of the arm and is tubed in the manner illustrated in Figure 61.1 In most cases, a skin graft is required to
cover the donor area.
OPERATIVE TECHNIQUE
The bipedicle is traditionally left for 3 weeks. In practice, either end of the flap could be transposed to the nose
first. Maintenance of antegrade circulation into the proximal end, with severance of the distal end, would seem
logical, but Tagliacozzi and others successfully severed the proximal end first (10, 11).
A second delay procedure of simply incising and resuturing the third side some 2 to 3 weeks before transposition
may be
performed (10). This is probably not necessary under ordinary circumstances, but it is usually done “for
security.”
FIGURE 61.1 A: The flap is prepared by creating a double-ended tube based on parallel incisions on the
anteromedial arm. The donor area can occasionally be closed directly, but usually requires a skin graft. B: The
distal end is severed and attached to the nasal bridge.
When the flap is attached to the nasal bridge, its area of contact with recipient nasal tissue is augmented
considerably if turndown flaps of local nasal skin have been used to line the defect. At this stage, satisfactory
fixation of the arm to the head is most important for patient comfort and for preventing traction of the tube from its
nasal attachment.
Tagliacozzi's method of fixation—using a preformed leather vest, hood, and series of straps to hold the palm onto
the scalp—was possibly more comfortable for the patient than the more expedient current method of adhesive
strappings or plaster of Paris headcap with arm splints and reinforcing struts.
After 3 weeks, the remaining brachial attachment is severed and the flap is left hanging from the nose for about
10 days, like an elephant trunk (9). This period allows an improvement of circulation and so permits a safer and
more radical defatting at the time of final shaping and insetting of the tip. This step reduces the number of
subsequent touch-up procedures required. Tagliacozzi advised flap severance at 14 to 20 days and shaping of
the tip 14 days later (Fig. 61.2).

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Methods in which the alae and columella are shaped first are more dangerous and require an additional delay
procedure (9, 12). However, such methods do have the advantage of facilitating fashioning of the tip region.
FIGURE 61.2 A: The proximally based flap is attached to the nasal bridge following a previous delay procedure.
B: The final result. There is no forehead deformity. The skin has a fine texture but does not have a good color
match. (From Mendelson et al., ref. 12, with permission.)
Further revisions are deferred until edema and induration resolve, usually between 3 and 6 months.
CLINICAL RESULTS
In the Mayo Clinic review of 180 nasal reconstructions (12), 10 Tagliacozzi flaps were used. There were no
flap losses and only one case of minor necrosis. The most frequent complication was infection (30%),
mostly at the donor site.
The median number of operations required was four over a 2-month period. The least number was four over
a 6-week period. An average of two subsequent touch-up procedures was required. Tagliacozzi's
description was of six operative steps over a period of 91 to 136 days.
An objective analysis of the quality of color match shows a marked disparity between the results achieved in
Caucasians and in those with pigmented skin. In a group of 14 Caucasian patients, half had excellent color
matches and all were satisfactory (9). In 10 Pakistani patients, most of the flaps developed
increased pigmentation, which often appeared after the delay prior to the flap transfer. Half the results were
regarded as poor matches (11).
No flap losses were reported in the 44 patients listed in the three published series reviews (9, 11, 12), an
impressive record for tubed pedicle flaps.
SUMMARY
The upper arm (Tagliacozzi) skin flap has been described for use in nasal reconstruction. It is one of the
oldest skin flaps in use, and it still has some application in present-day plastic surgical practice.

References
1. Tagliacozzi G. De curtorum chirurgia per insitionem (icones). Venice: Bindoni, 1597.
2. Gnudi MT, Webster JP. The life and times of Gaspare Tagliacozzi. New York: Herbert Reichner, 1950.
3. Nelaton C, Ombredanne L. La Rhinoplastie 1904.
4. Reneaume de la Garanne. Histoire de l'Academie Royale des Sciences. Paris, 1712;29.
5. Von Graefe O. Rhinoplastik. Berlin, 1818.
6. Dieffenbach IF. Operative Chir 1845;1:327.
7. Fabrizi O. Gaz Hop 1841.
8. Ortiz-Monasterio F, Olimedo A, Barrera G. A modified Tagliacotian rhinoplasty. Br J Plast Surg
1978;31:66.
9. Arregui K, Murray JE, Cannon B. The use of arm flaps for “facial defects.” In: Transactions of the 3rd
International Congress of Plastic Surgery. Amsterdam: Excerpta Medica, 1963.
10. Conway H, Stark R, Nieto Cano G. The arterial vascularization of pedicles. Plast Reconstr Surg
1953;12:348.
11. Blocksma R, Innis CO. Reconstruction of the amputated nose: report on 30 cases. Plast Reconstr Surg
1955;15:390.
12. Mendelson BC, Masson JK, Arnold PG, at al. Flaps used for nasal reconstruction: a perspective based
on 180 cases. Mayo Clin Proc 1979; 54:91.

Chapter 62
Trapezius Musculocutaneous Island Flap
W. R. PANJE
EDITORIAL COMMENT
The trapezius musculocutaneous flap, as outlined, is supplied by the branches of the transverse cervical
artery. It would be difficult for the flap to consistently reach the glabellar area for a secure attachment. A
wide area of attachment would allow more effectively for greater circulation than the so-called training
technique. This particular method of nasal reconstruction should be considered after other simpler and
more effective methods have been discarded.
Surgical reconstruction of a total nasal defect can be effectively accomplished by using the trapezius
musculocutaneous extended island flap.
INDICATIONS
This flap provides the abundant cutaneous tissue required for total nasal reconstruction without the need
for delay. It also offers an excellent color match. The procedure can be accomplished in a two-staged
operation, leaving a relatively hidden donor site. No external cast immobilization is required in the transfer of
this regional flap to the face.
ANATOMY
For the first stage of this procedure, an extended trapezius musculocutaneous island flap is developed based on
the transverse cervical vessels. The accessory nerve innervation to the remaining trapezius muscle can be
preserved. Once the flap is divided prior to insetting, it has, of course, a random-pattern circulation.
FLAP DESIGN AND DIMENSIONS
As with other methods of total nasal reconstruction, the initially reconstructed nose should be 20% to 30% larger
than the desired final goal because of shrinkage. A cutaneous segment of flap 16 cm long by 10 cm wide is
elevated onto the trapezius muscle carrier, which is 16 × 5 cm.
OPERATIVE TECHNIQUE
Initially, a triangular incision (the apex located over the acromion) is made lateral to medial along the clavicle and
the anterior border of the trapezius muscle to allow identification of the transverse cervical vessels into the
posteroinferior part of the neck. This incision provides access to the lower neck for identification of the posterior
belly of the omohyoid muscle (crucial for convenient location of the transverse cervical vessels) and dissection of
the trapezius muscle and eleventh nerve. It also allows external delivery of the vascular pedicle from the neck to
increase the arc of the flap. In dissecting the transverse cervical vascular pedicle, overzealous exposure of the
vessels should be avoided.
The distal cutaneous portion of the flap, dissected caudal to the scapular spine, is tubed onto itself. The end is
attached to a cephalic-based half-circle flap developed over the glabella (Fig. 62.1). The length of the half-circle

or trapdoor flap should equal the radius of the tubed portion of the flap. The muscle portion of the flap is not
rolled onto itself because of bulkiness and the risk of compressing the vascular pedicle.
The patient's head should be positioned to avoid tension, and the flap should be allowed to heal in place for
about 18 days. Since the flap is relatively heavy, it will need additional support during the healing phase. This
can be provided, in part, by suturing the flap to the edges of the defect. External support also may be necessary.
The skin portion of the flap should measure at least 12 cm. This should allow the end of the flap (now the distal
portion) to reach the level of the mental crease. Training of the flap is begun with intermittent clamping as
tolerated. The flap is then severed from its shoulder attachment. Excess muscle and fat are removed from the
distal part of the flap. It is important not to damage the subdermal plexus during this maneuver, since the flap has
become completely randomized and depends on the plexus for nutrition. The proximal part (5 cm) of the flap is
not debulked.
FIGURE 62.1 Trapezius musculocutaneous island flap elevated and attached to the glabella. (From Panje, ref. 1,
with permission.)
The undersurface of the tubed portion of the flap is incised to leave some skin for lining (Fig. 62.2). The flap is
then sutured to the nasal defect using a two-layered closure. The distal part of the flap is then folded on itself, as
shown in Figure 62.2. The distal corners of the flap will approximate each other at a midpoint about 5 to 7 cm
from the flap's distal edge. This infolding creates the columella and nasal alae while providing the lining for the
nasal vestibule. The nares are packed for 5 to 7 days in order to obliterate the dead space.
The reconstructed nose will usually undergo shrinkage within 3 or 4 months. During this period, the nares should
be supported. Further minor procedures, such as debulking, refashioning, or adding dorsal support, may be
required. The patient should start shoulder exercises within the first week to prevent stiffness (Fig. 62.3).
FIGURE 62.2 The undersurface of the flap. By making the incisions shown in the tubed portion, lining is provided
for the internal surface of the nose. Infolding the distal portion of the flap not only forms the alae and columella,
but also lines the nasal vestibules. (From Panje, ref. 1, with permission.)
CLINICAL RESULTS

A significant muscle paralysis can occur if care is not taken to prevent injury to the accessory nerve. It
should be remembered that there are several distally located eleventh nerve branches that innervate the
trapezius. Frequently, the most distal branch will be cut in isolating the transverse cervical vessel pedicle.
However, the proximal branches to the trapezius can be preserved with maintenance of muscle function.
SUMMARY
A trapezius musculocutaneous island flap can be used to reconstruct the total nasal defect.
FIGURE 62.3 A: One year following total rhinectomy. B: One month after total nasal reconstruction using
the trapezius musculocutaneous island flap. C: One year postoperatively. (From Panje, ref. 1, with
permission.)
Reference
1. Panje WR. A new method for total nasal reconstruction: the trapezius myocutaneous island paddle flap.
Arch Otolaryngol 1982;108:156.

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Chapter 63
Microvascular Free Transfer of A Retroauricular Skin Flap
T. FUJINO
M. WADA
EDITORIAL COMMENT
This would appear to be an exceptionally difficult flap to transfer successfully, because of the variability of
the blood supply and the disparity in size between donor and recipient vessels. The success of this flap
may, in fact, depend on inosculation of the thin flap.
Retroauricular skin, located at the back of the ear, provides a good color match for facial cover. A free skin flap
based on the retroauricular vessels can be designed in this area (1).
ANATOMY
The retroauricular artery usually arises from the external carotid artery (in 93% of cases) and runs relatively
deep,
passing through the parotid gland. It emerges in front of the anterior surface of the mastoid process behind the
auricle. Because this artery lies 3 cm beneath the skin near the mastoid process, one might anticipate problems
when preparing it for transfer. Inasmuch as the external diameter of this artery near the mastoid process is about
1.2 mm, however, we found that preparation was not difficult. Furthermore, the retroauricular artery rises upward
abruptly at the mastoid process to a position 1 cm below the skin surface in the central portion of the posterior
aspect of the auricle. It is therefore possible to expose this artery through careful dissection. It should be kept in
mind that in 7% of cases, the retroauricular artery also arises from the occipital artery (Fig. 63.1A) (2, 3).
The retroauricular artery distributes some branches behind the auricle and supplies the flap area. The artery
runs lateral and slightly posterior to the facial nerve trunk. Thus, with care, injury to this nerve during preparation
of the flap can be avoided.
The relationship of the artery to the greater auricular nerve is not uniform. The retroauricular vein does not
always accompany the artery. It courses in a more superficial zone, usually 1.5 cm below the skin surface of the
mastoid region and 0.3 cm below the surface behind the auricle. The mean external diameter of the vein behind
the auricle is 1.4 mm; it appears abruptly as it ascends above the auricle. The vein is situated in a
posterosuperior position to the artery.

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FIGURE 63.1 A: Diagram of the free retroauricular flap. On the left, the retroauricular artery (a) originates from
the external carotid and supplies the entire flap region. On the right, the retroauricular artery (a) originates from
the external carotid artery and supplies the lower portion of the flap. A second artery (b) originates from the
occipital artery and supplies the upper portion of the flap. B: An example of a free retroauricular skin flap (RA,
retroauricular artery; RV, retroauricular vein; ECA, external carotid artery; EJV, external jugular vein).
FLAP DESIGN AND DIMENSIONS
A free retroauricular skin flap 5 × 7 cm in average size can be fashioned. The flap can be extended further by
taking into account the anastomosis between the retroauricular artery and the superficial temporal artery. The
proposed flap design is marked along the area just behind the helix distally, along the hairline proximally, at the
tip of the helix cranially, and at the lowest part of the earlobe caudally (Fig. 63.1).
OPERATIVE TECHNIQUE
The incision is started just behind the helix and proceeds deep and above the perichondrium toward the concha.
At the junction of the mastoid process and concha, a paired perforating artery and vein 1 mm in diameter,
respectively, are found. To obtain a long vessel axis, the perichondrium is incised, and dissection is further
carried out deep along the mastoid process (Fig. 63.2) (1, 4).

FIGURE 63.2 A: A 24-year-old man with a huge cavernous hemangioma with bleeding from the lower eyelid
every other day and a progressive decrease in vision. The patient had received radiation therapy at the age of 4
years. Bilateral carotid angiograms showed extensive involvement of the right orbit and maxillary sinus, with
some abnormal patterns in the left orbit and maxillary sinus. B: Design of the flap on the back of the ear. C: On
the first postoperative day it was necessary to remove all sutures from the flap edges. This was followed by good
bleeding from all edges. D: Eleven months after the free flap to the nose and 10 months after the combined
procedure on the cheek. (From Fujino et al., ref. 1, with permission.)
CLINICAL RESULTS
In a single attempt at resection of a large hemifacial cavernous hemangioma and resurfacing of the nose
with a retroauricular skin flap, the flap survived and there was no functional deficit. Unless the concomitant
vein is anastomosed, vascular circulation might be impaired temporarily, because of an incompletely closed
vascular circuit. In this situation, undue tension after microvascular anastomosis is contraindicated.
SUMMARY
A good color match can be obtained by using a free retroauricular flap to resurface facial defects.
References

1. Fujino T, Harashina T, Nakajima T. Free skin flap from the retroauricular region to the nose. Plast
Reconstr Surg 1976;57:338.
2. Wada M. A contribution to the study of the topographic relationships between blood vessels and nerves.
Jpn Keio Med Soc. 1978;55:149.
3. Wada M, Fujino T, Terashima T. Anatomic description of the free retroauricular flap. J Microsurg
1979;1:108.
4. Fujino T, Ikuta Y, Harashina T. Technique of microsurgery. In: Fujino T, ed. Tokyo: Igakushoin, 1977;72-
76.

Chapter 64
Microvascular Free Transfer of A Retroauricular Flap
S. KOBAYASHI
EDITORIAL COMMENT
This chapter extends Washio's technique of a pedicled retroauricular flap using microvascular techniques.
The flap is a good one, but the anatomy is variable and therefore not always totally reliable.
A skin flap from the retroauricular area can be elevated on the posterior auricular vessels. The flap provides thin
skin that matches facial skin in color and texture, with minimal donor-site deformities, and with the donor site
easily hidden by hair. This flap has not been too widely used as a free flap, because the involved vessels are
sometimes too small.
INDICATIONS
A retroauricular skin flap can be used in the treatment of medium-sized defects of the intraoral mucosa,
nose, eyelid, and eye socket (1, 2-4). It can also be used to correct composite defects which include hair,
such as skin defects in the hair-bearing area of the temporal hairline, preauricular sideburns, and upper
eyelid-eyebrow region. The transitional zone from skin to hair can be naturally restored through the
incorporation of hair in the flap, particularly when compared to conventional two-stage techniques (5).
ANATOMY
The retroauricular mastoid skin is supplied mainly by the posterior auricular artery (PA). This vessel usually
branches off from the external carotid artery, and it ascends between the parotid gland and the styloid process of
the temporal bone, to the groove between the cartilage of the auricle and the mastoid process. The PA supplies
the skin located in the posterior aspect of the auricle. The posterior auricular vein does not always run along with
the artery; instead, it may be located in a more superficial and posterior position vis-à-vis the artery. Anatomic
variations of the posterior auricular vessels have been reported in the literature (4,6,7). The diameter of these
vessels is sometimes too narrow for use in free-flap transfer (Fig. 64.1).
Flaps can be elevated from the retroauricular area based on the tributaries of the superficial temporal artery
(STA), i.e., the posteriorly running branch of the parietal branch of the STA, or the anterior auricular branches of
the STA; the posterior auricular vessels have a vascular network running between these STA tributaries (3,8). A
flap based on the STA sometimes tends to become congested (5).

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FIGURE 64.1 Blood supply around the ear (PB, parietal branch of STA; PRB, posteriorly running branch of
parietal branch of STA; AAB, anterior auricular branches of the STA; PA, PV, posterior auricular artery and vein).
FLAP DESIGN AND DIMENSIONS
Retroauricular mastoid skin, measuring up to about 6 × 6 cm, can be safely elevated in adult patients, based on
the posterior auricular vessels and transferred when the vessels have a reliable diameter of approximately 1 mm,
and when a reliable vein can be included in the flap. The retroauricular skin located at the helical margin must be
preserved to prevent auricular deformities after flap harvesting. When it is necessary to transfer the
retroauricular hairline, a hairline of about 1 to 2 cm in width can be added to the flap.
Since the diameter of the posterior auricular vessels varies between individuals, preoperative assessment of the
vessels is recommended, using a color Doppler flow imager. Without invasive techniques, this device can be
used to determine the approximate diameter of the vessels and the direction of the blood flow.
OPERATIVE TECHNIQUE
The skin incision line on the lower flap edge is extended along the anterior margin of the sternocleidomastoid
muscle; the artery and vein are identified. Great care should be taken at this point, because the diameter of
these vessels may be less than 1 mm. Since the vessels run deep between the sternocleidomastoid muscle and
the posterior surface of the parotid gland, the vessels should be carefully dissected, to avoid damage to the
neighboring facial nerve. The posterior auricular artery increases in diameter in the proximal area close to the
branching of the stylomastoid artery. When a retroauricular flap is used as a free flap, the artery must be
dissected from at least this branching point to the proximal region. Once vessel dissection is completed, the flap
is elevated down to the subaponeurotic area. If the posterior auricular vessels are too narrow for transfer as a
free flap, the flap should be elevated based on the tributaries of the STA.

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FIGURE 64.2 A: A 41-year-old woman had a hemangioma on the upper eyelid, temporal and forehead region.
The entire area, with the exception of the eyebrow, had been treated with a split-thickness skin graft at another
hospital; ectropion of the lid occurred. Texture and color of skin grafts did not match the surrounding skin. B: A
retroauricular hairline flap was transferred to reconstruct the upper eyelid and eyebrow in one stage. The
posterior auricular vessels were anastomosed to the anterior branch of the superficial temporal vessels. The
resulting upper eyelid was too bulky; although the transferred skin was thin, subcutaneous tissue in the flap
included fascia and loose areolar tissue that increased total flap thickness. C,D: Two secondary revisions were
performed, including excision of subcutaneous structure of the transferred flap, to correct bulkiness in the upper
eyelid. Results obtained were satisfactory, with a natural-appearing hair transitional zone achieved from the
eyebrow to the upper eyelid. Skin color and texture of the transferred flap matched the facial skin, with minimal
donor-site defect.
CLINICAL RESULTS
In the transfer of seven retroauricular free flaps based on the posterior auricular vessels, we have had no
flap losses (Fig. 64.2). In an additional two cases, preoperative planning
had involved raising the flap with the same vessels, but we decided to switch to an STA pedicle flap. This
was based on an intraoperative assessment that the posterior auricular vessels were too narrow for
microvascular anastomosis, especially the posterior auricular vein.
SUMMARY
This flap is extremely useful in reconstructing facial skin defects. It provides a good skin color and texture
match, and hairline defects can be managed in one stage. However, when this flap is raised, careful

attention must be paid to anatomic variations in the blood vessels and vascular network around the ear.
Reference
1. Fujino T, Harashina T, Nakagima T. Free skin flap from the retroauricular region to the nose. Plast
Reconstr Surg 1976;57:338.

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Chapter 65
Nasal Reconstruction With Auricular Microvascular Transplant
J. J. PRIBAZ
D. L. ABRAMSON
EDITORIAL COMMENT
This technique extends the use of the procedure of selecting appropriate portions of the ear for nasal
reconstruction. By accomplishing microvascular anastomosis, assurance of the survival of the segments is
far more likely.
The ascending helix of the ear is a laminated structure composed of cartilage surrounded by a thin, tightly
adherent layer of skin. This composite tissue provides all that is necessary for reconstruction of full-thickness
defects of the ala and columella. Composite grafts are frequently used to repair defects of the nasal ala (1, 2, 3,
4). Although technically relatively easy to perform, they are limited by problems with viability, dimension, and
atrophy. A free-tissue transfer harvested from the ascending helix can be used to repair defects of the distal part
of the nose, including nasal sill, ala, tip, and columella (5, 6, 7).
INDICATIONS
Patients with full-thickness defects of the nasal tip, sill, ala, and columella, which would yield suboptimal
results with a composite graft, should be considered for the procedure. Selection should include those
patients with major concerns about further scarring of the midface or forehead. In addition, those who have
undergone reconstructive attempts with more conventional techniques that have failed, are candidates for
this procedure. Advantages of this flap include possible modifications of flap dimensions and orientation, to
allow replacement of any portion of the distal hemi-nose. The flap is supplied by branches arising from the
superficial temporal vascular pedicle, making microvascular transfer technically feasible. The size of the flap
is limited only by the resulting donor deformity.
ANATOMY
Nose and auricular cadaver specimens were compared and, when superimposed, the unfolded nostril is very
similar to the ascending helical rim (Fig. 65.1). Both the ascending helix and the nostril consist of laminated
cartilage surrounded by a skin envelope. If the nostril sill is to be reconstructed, the crus of the helix can be
included in the flap (Fig. 65.2). Microfil radiopaque dye was used to assess the vascularity of this region. One to
three branches arising from the superficial temporal artery supplied this portion of the ear.

FIGURE 65.1 The “unfolded” nose is superimposed over the ascending helix of the ear in a cadaver specimen.
FLAP DESIGN AND DIMENSIONS
The first step in designing the flap is to define the defect. Bone wax can be used to fashion a three-dimensional
model. The model can be transferred to the ascending helix and used to determine the amount of skin and
cartilage required, as well as the orientation of the tissue to be included in the flap (Fig. 65.2).
FIGURE 65.2 A: A 28-year-old woman with deficiency of the right ala and nostril sill, despite multiple
reconstructive attempts after sarcoma excision. B: A wax model has been made of the defect, then transferred to
the contralateral ear, and the flap marked along the crus of the helix and the ascending helical rim. The
superficial temporal vessels have been marked out after Doppler examination. The anatomy of this flap is
depicted. White dots from the vessels to the outline of the flap represent the subcutaneous tissue that is
harvested with the flap.
OPERATIVE TECHNIQUE
As stated above, a small model of the defect should be made. The flap should then be designed on the
ascending helix to provide a symmetric reconstruction. For alar and nostril-sill reconstruction, the contralateral
ear is used; for columella reconstruction, either ear can be used.

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A preauricular incision is made, and the superficial temporal vessels are isolated above the ear. When harvesting
this flap, no effort is made to dissect the individual small branches of the superficial temporal artery that supply
the upper third of the ear. Instead, subcutaneous tissue in the preauricular area is harvested in continuity with
the superficial temporal vessels and ascending helical rim. The appropriate recipient vessels, usually the facial
artery and vein, are isolated through an incision in the nasolabial fold.
The flap is then transferred, inset, and anastomoses performed. Cases with multiple previous surgical
procedures may require the use of vein grafts to reach recipient vessels in the upper neck. The facial artery is
usually of good caliber, but sometimes the facial vein, which is usually located more laterally, may be quite small.
If it is deemed unsuitable, then a vein graft will be needed to the upper neck. The donor defect is closed through
a combination of advancement of the helical rim, as described by Antia and Buck (8), and a cheek advancement
or postauricular flap.
FIGURE 65.3 A: A 42-year-old woman with an arteriovenous malformation involving the columella and upper lip.
The lesion was radically resected. B: Planned flap marked on the ascending helix of the right ear. C: Immediate
postoperative result. D,E: Long-term result 3 years postoperatively.

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CLINICAL RESULTS
The ascending helix can be used as a microvascular transfer to correct many defects of the distal hemi-
nose. Our experience includes reconstruction of the nasal tip, ala, columella, and sill, or combinations of
these. Defects were created following excision of arteriovenous malformations, basal cell carcinoma (BCC),
small-cell carcinoma (SCC), and sarcoma, as well as a single case following a human bite. This procedure
was performed in patients ranging from 7 to 76 years of age.
The flap is versatile in reconstructing a variety of nasal defects, with size limited only by the donor deformity
of the ear. In our experience, patients usually undergo a secondary procedure, either minor scar revisions
or debulking of the flap pedicle (Figs. 65.2 and 65.3).
SUMMARY
The use of the auricular free flap requires a substantial effort, but can provide an elegant and predictable
result for selected patients with defects of the distal nose. The ideal candidate for this procedure would be a
patient who desires excellent color and contour match, but wishes to avoid cheek or forehead donor
morbidity.
References
1. Joseph J. Nasenplastic und sonstige Gesichtsplastik. Leipzig: Kabitzsch, 1931.
2. Brown JB, Cannon B. Composite free grafts of skin and cartilage from the ear. Surg Gynecol Obstet
1946;82:253.
3. Dupertuis SM. Free ear lobe grafts of skin and fat. Plast Reconstr Surg 1946;1:135.
4. Converse JM. Reconstruction of nasolabial area by composite grafts from concha. Plast Reconstr Surg
1950;5:247.
5. Lin SD, Lin GT, Lai GS, et al. Nasal alar reconstruction with free “accessory auricle.” Plast Reconstr Surg
1984;73:827.
6. Parkhouse N, Evans D. Reconstruction of the ala of the nose using composite free flap from the pinna. Br
J Plast Surg 1985;38:306.
7. Pribaz JJ, Falco N. Nasal reconstruction with auricular microvascular transplant. Ann Plast Surg
1993;31:289.

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Chapter 66
Nasal Alar Reconstruction With An Ear Helix Free Flap
S. M. SHENAQ
T. A. DINH
M. SPIRA
EDITORIAL COMMENT
This procedure provides a very elegant reconstruction of the nasal alar region; however, the surgeon must
be expert in microvascular techniques.
A vascularized chondrocutaneous free flap from the root of the auricular helix can serve as a solution to the
problem of alar reconstruction. It is unlike local flaps that may result in additional facial scarring and bulky alae
that require multiple thinning revisions. This flap produces satisfactory symmetry between the two alae and a
good color match. The donor defect can be concealed with hair in female patients (1, 2, 3, 4, 5, 6, 7, 8, 9, 10).
INDICATIONS
The structural similarities between the alae and the auricular helices have allowed the use of free helical
composite grafts to repair small nasal defects of less than 2.0 cm (11, 12, 13, 14, 15, 16). More recent
delineation of the vascular territories of the ear has allowed the use of vascularized helical free flaps in the
repair of large alar defects. With a chondrocutaneous microsurgical free flap from the root of the auricular
helix, a successful reconstruction of a 3.2 × 3.0 cm full-thickness alar defect is possible.
This flap has several advantages: (a) The size of the flap can be easily tailored to the needs of
reconstruction; this is especially important in large defects. (b) Similarities in the structure, contour,
thickness, and color match between the helical rim and the nasal ala minimize the need for later revision
and often provide superior reconstructive results over local flaps, especially for large defects. (c) The donor
defect is acceptable and easily covered with temporal hair, especially in female patients. (d) When required,
this flap facilitates the reconstruction of the base of the ala at the alar/cheek angle.
Disadvantages include the requirement for microsurgical expertise to perform this type of procedure, and
the considerable additional time necessary, compared to more standard procedures.
FIGURE 66.1 Basal view of alar defect after cancer excision.

ANATOMY
The ala nasi consists of external skin, cartilaginous support, and inner lining. The normal ala is thin, but contains
enough cartilage to prevent its collapse. The helical rim of the ear and the alar rim are the only places in the
body where “skin abuts skin,” an important reason why reconstruction is so difficult. The auricular helix contains
a sufficient amount of supporting cartilage enveloped in thin skin, very similar to the structure of the natural ala
nasi. The thin helical edge closely resembles the thin alar rim. That part of the helix is chosen that best
approximates the contour of the ala, thus minimizing the need for secondary procedures. Microsurgical technique
allows successful transference of a composite flap in a one-stage free-flap procedure, utilizing the root of the
helix and adjacent preauricular skin.
FLAP DESIGN AND DIMENSIONS
For reconstruction of the left ala, the right auricular helix is chosen. The superficial temporal vessels of the flap
are placed at the inferior lateral angle of the helix, thus allowing for better reach. The left anterior superficial
temporal artery and vein are also preserved as a second backup vascular source.
OPERATIVE TECHNIQUE
The procedure is described in a 36-year-old woman with squamous-cell carcinoma involving the left alar rim,
nostril, and lower alar cartilage that required excision. The residual defect measured 3.2 × 3.0 cm, and the septal
mucosa was clearly visible through the defect (Fig. 66.1). One-year follow-up postexcision showed no sign of
cancer recurrence.
FIGURE 66.2 Close-up intraoperative photographs showing defect (A) before and (B) after preparation for
reconstruction.
The procedure was performed under general anesthesia. Intraoperatively, the margins of the defect were found
on frozen section to be free of any malignancy (Fig. 66.2). The facial vein was isolated through an incision along
the nasolabial crease. Because of sclerosis of the facial and superior labial arteries, the superficial temporal
artery on the ipsilateral side was chosen to be the recipient artery via a 12-cm vein graft from the foot.
An appropriate outline of the left alar defect, measuring 3.5 × 3.0 cm, was marked on the superior helix of the
right ear to include a portion of the preauricular skin. The proximal portions of the superficial temporal vessels
were exposed and skeletonized for approximately 4 cm, to achieve an adequate pedicle length. The flap was
elevated to include the root of the helix and adjacent preauricular skin (Fig. 66.3).
The flap was inserted into the defect, and restoration of the alar rim was achieved (Fig. 66.4). The free flap was
revascularized by anastomosing its arterial vascular pedicle to the left superficial temporal artery, employing the
vein graft previously mentioned. The vein was then anastomosed to the facial vein lying under the nasolabial
fold. Standard microvascular techniques were employed, using simple interrupted sutures of 10-0 nylon for the
anastomosis.

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The donor defect on the right ear was covered by advancing skin over the exposed cartilage and closed with
multiple interrupted sutures of 4-0 nylon. The vein-graft donor site was closed. The entire surgical procedure
took approximately 7 hours.
CLINICAL RESULTS
There was an uncomplicated postoperative course, and no donor-site problems were encountered. A minor
scar revision of the flap edges was performed 4 months later. One-year follow-up showed satisfactory
symmetry between the two alae and a good color match. The donor site on the right ear could be concealed
with hair (Fig. 66.5).
SUMMARY
The ear, because of its similar structure, color, texture, and contour, provides excellent tissue for
reconstruction of the ala, columella, and nasal tip. Vascularized helical free flaps provide a good solution to
the problem of repairing large alar full-thickness defects.
FIGURE 66.3 Intraoperative photographs showing the helical composite chondrocutaneous free flap, (A)
during and (B) after harvest, with its superficial temporal vessels.
FIGURE 66.4 Left ala immediately postinsertion of flap.

FIGURE 66.5 Donor site at 1-year follow-up.
References
1. Hallock GG, Dreyer TM. The stair-step flap for nasal alar reconstruction. Ann Plast Surg 1987;18:34.
2. Hirshowitz B, Kaufman T, Ullman J. Reconstruction of the tip of the nose and alar by load cycling of the
nasal skin and harnessing of extra skin. Plast Reconstr Surg 1986;77:316.
3. Gliosci A, Sabbagh E, Hipps CJ. Reconstruction of the ala of the nose by local pedicle flap. Plast Reconstr
Surg 1968;41:149.
4. Fox JW IV, Golden GT, Edgerton MT. Surgical correction of absent nasal alae of the Johnson-Blizzard
syndrome. Plast Reconstr Surg 1976;57:484.
5. Hardin JC Jr. Alar rim reconstruction by a dorsal nasal flap. Plast Reconstr Surg 1980;66:2293.
6. Pers M. Cheek flaps in partial rhinoplasty. Scand J Plast Reconstr Surg 1967;1:37.
7. Herbert DC. A subcutaneous pedicled cheek flap for reconstruction of alar defect. Br J Plast Surg
1978;31:79.
8. Spear SL, Kroll SS, Romm S. A new twist to the nasolabial flap for reconstruction of lateral alar defects.
Plast Reconstr Surg 1987;79:915.
9. Hauben DJ, Sagi A. A simple method for alar rim reconstruction. Plast Reconstr Surg 1987;80:839.
10. Washio H. Retroauricular-temporal flap. Plast Reconstr Surg 1969;43:162.
11. Konig F. Ueber nasenplastik. Beitr Klinish Chir 1914;94:515.
12. Dupertius SM. Free ear lobe grafts of skin and fat. Plast Reconstr Surg 1946;1:135.
13. Field LM. Nasal alar rim reconstruction utilizing the crus of the helix, with several alternatives for donor
site closure. J Dermatol Surg Oncol 1986;12:253.

14. Lehman JA, Garrett WS Jr, Musgrave RH. Earlobe composite grafts for the correction of nasal defects.
Plast Reconstr Surg 1971;47:122.
15. Lin SD, Lin GT, Lai CS, et al. Nasal alar reconstruction with free “accessory auricle.” Plast Reconstr
Surg 1984;73:827.
16. Parkhouse N, Evans D. Reconstruction of the ala of the nose using a composite free flap from the pinna.
Br J Plast Surg 1985;38:306.

Chapter 67
Microvascular Free Transfer of A Compound Dorsalis Pedis Skin
Flap With Second Metatarsal Bone
K. OHMORI
EDITORIAL COMMENT
Using the long leash of the dorsalis pedis anterior tibial arterial system, a more assured blood supply can be
found. The vessels can then be brought down to the neck to the external carotid and jugular systems. Use
of the temporal artery is not as secure as use of the larger arterial vessel.
Total nasal reconstruction can be achieved by including the second metatarsal bone with a free dorsalis pedis
skin flap (1).
INDICATIONS
There are not many indications for use of this procedure, especially when the patient has normal forehead
and cheek skin.
ANATOMY
A detailed description of the vascular anatomy of this flap can be found in Chapter 548 (2, 3).
Arterial Supply
Based on my clinical experience, it is unnecessary to keep all the small branches of the dorsalis pedis or the first
dorsal metatarsal arteries intact. For example, I routinely pull out the extensor brevis muscle after severing its
tendon.
Venous Drainage
Either the cutaneous vein (which is directly connected to the greater and lesser saphenous veins) or the venae
comitantes of the anterior tibial, dorsalis pedis, and first dorsal metatarsal arteries can be selected. However, to
obtain the long vascular pedicle needed for this flap, it is easier to use the venae comitantes.
FLAP DESIGN AND DIMENSIONS
The entire dorsal aspect of the foot can be used. If necessary, the flap can be extended to include the skin
overlying the second toe. Both the second metatarsus and the toe itself can be included.
The axis of the flap should lie over the course of the dorsalis pedis or first dorsal metatarsal artery. The flap
should be centralized over the base of the second metatarsal bone (Figs. 67.1 and 67.2).

FIGURE 67.1 A free compound dorsalis pedis skin flap with second metatarsal bone. Note the long vascular
pedicle.
FIGURE 67.2 The usual size and position of the free dorsalis pedis compound flap.

FIGURE 67.3 A,B: Design of the local turnover flaps to provide lining. C: The forehead flap is turned down to
allow good exposure while performing the microvascular anastomoses between the long vascular pedicle of the
donor flap and the recipient superficial temporal vessels. D: The suture lines at the completion of the procedure.
(From Ohmori et al., ref. 1, with permission.)
OPERATIVE TECHNIQUE
Donor Site
The first incision is made in the first web space, and the first dorsal metatarsal artery is dissected out. The artery
is ligated distally, and the extensor hallucis brevis tendon is transected just before its insertion. The flap is then
raised along its medial and lateral borders by dissecting just above the paratenon of the extensor digitorum
longus and the extensor hallucis longus tendons.
The extensor digitorum brevis is pulled out proximally from the lateral side of the dissection. Then the lateral
tarsal artery and vein are ligated.
The medial tarsal artery and vein are ligated from the medial side of the dissection. Since the extensor hallucis
longus tendon hinders raising of the flap, the tendon must be dissected carefully without damaging its paratenon.
The tendon can then be pulled out medially, allowing ligation of the medial tarsal vessels. The dissection
proximal to the base of the second metatarsal bone may be completed by raising the flap from the tarsal bone.
When only a skin flap is required, dissection of the flap is carried out from a distal point to the base of the second
metatarsal bone, carefully avoiding damage to the first dorsal metatarsal vessels.

FIGURE 67.4 A: The defect in a 47-year-old woman who had some unknown disease at age 14. The skin of the
face was atrophied and showed many smallpox-type scars. B: The postoperative result.
When an osteocutaneous free flap is required, the base of the second metatarsal bone is osteotomized from the
lateral side. The flap is then raised with the bone and its attached interosseous muscle. After severing the
metatarsophalangeal joint of the second toe, the distal portion of the flap is dissected. Most of the interosseous
muscles between the first and second metatarsal bones and the first dorsal metatarsal vessels are raised en
bloc.
Finally, the terminal branch of the dorsalis pedis artery is ligated. This operative procedure is performed with
great care to avoid damaging the connection of the dorsalis pedis vessels to the first dorsal metatarsal vessels.
When a long vascular pedicle is required, the incision must be extended proximally along the course of the
anterior tibial artery. Using this method, a flap with a vascular pedicle more than 20 cm in length can be obtained.
The donor defect is skin grafted.
Recipient Site
Intranasal lining can usually be obtained by the use of turnover flaps (Fig. 67.3A and B). The superficial temporal
vessels are dissected out underneath a forehead flap to facilitate microvascular anastomoses (Fig. 67.4) (4, 5).
CLINICAL RESULTS
In my unit, 19 dorsalis pedis flaps, with or without second metatarsal bone, were transferred by means of
microvascular anastomoses. In this series, only one flap underwent partial necrosis. Of these 19 patients,
two underwent nasal reconstructions.
SUMMARY
The use of a free dorsalis pedis flap for nasal reconstruction has been described. The second metatarsal
bone can be included with the flap to provide nasal support.
References

1. Ohmori K, Sekiguchi J, Ohmori S. Total rhinoplasty with a free osteocutaneous flap. Past Reconstr Surg
1979;63:387.
2. McCraw JB, Furlow LT Jr. The dorsalis pedis arterialized flap. Plast Reconstr Surg 1975;55:177.
3. Man D, Acland RD. The microarterial anatomy of the dorsalis pedis flap and its clinical applications. Plast
Reconstr Surg 1980;65:419.
4. Ohmori K, Harii K. Free dorsalis pedis sensory flap to the hand with microneurovascular anastomoses.
Plast Reconstr Surg 1976;58:546.
5. Robinson DW. Microsurgical transfer of the dorsalis pedis neurovascular island flap. Br J Plast Surg
1976;29:209.

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Chapter 68
Nasal Vestibular Chondromucosal Flap
D. R. MILLARD JR.
EDITORIAL COMMENT
The editors feel that correction of the retruded columella could be accomplished by shortening the nose as
the author did, but it also could be achieved by judicious placement of cartilaginous grafts to the columella.
In correcting notching of the alar rim, the described procedure is indicated when a shortage of nasal lining
but an adequate amount of external nasal skin are present.
The chondromucosal flap for correction of columellar retraction after septal resection was first described in 1963
(1). This flap has several donor areas and great versatility, and it is available for unilateral or bilateral use (2, 3).
INDICATIONS
When the columella is retracted, the nasal tip is depressed from lack of anterior septal support, and the
lateral side walls are relatively long, then lateral chondromucosal flaps, including portions of the lower
lateral alar cartilage, are available (Fig. 68.1A). When there is a hanging columella that is exaggerated by
retracted lateral side walls or even collapse of the alar margins and nasal obstruction, reverse
chondromucosal flaps are available (Fig. 68.2A).
These flaps are also available for a unilateral deformity and can even be taken from one lateral vestibule
and slid subcutaneously over the septum to supply the opposite side. (The temporary fistula can be closed
after several weeks.)
During reconstruction of a columella or side wall, the chondromucosal flaps can be used to provide lining
and support. These flaps also can be quite helpful in conjunction with a nasolabial skin covering flap.
ANATOMY
This is a compound flap containing lining and cartilage. The vascular dependability of this flap is remarkable,
considering the hazardous width-to-length ratio. This is probably due to
the fact that the flap is backed by cartilage, which acts as a splint to prevent collapse or kinking of the vessels
within it.

FIGURE 68.1 A: Retracted columella, long side walls, and depressed nasal tip. B: Lateral vestibular
chondromucosal flap marked and being cut with an anterosuperior base. C: Chondromucosal flap being
transposed into membranous septal releasing incision. D: Bilateral transposition of these flaps, sutured into
place. E: Side wall lifted as columella is released and nasal tip elevated slightly. (B-D from Millard, ref. 3, with
permission.)
FIGURE 68.2 A: Retracted alae and hanging columella. B: Chondromucosal flaps taken from membranous
septum based anteriorly and superiorly. C: Flap being transposed into vestibular alar releasing incision. D:
Bilateral transposition of these flaps, sutured into place. E: Simultaneous correction of hanging columella and
retracted alae.
FLAP DESIGN AND DIMENSIONS
The chondromucosal flap is relatively narrow (0.5 to 0.75 cm wide) and at least four to five times longer than it is
wide. Viability and maneuverability depend on its base, which is superior and anterior high up under the tip and
above the front point of the septum (Figs. 68.1B and 68.2B).

OPERATIVE TECHNIQUE
Retracted Columella and Depressed Nasal Tip
The membranous septal incision that releases the retracted columella should be extended laterally along
the standard inter-cartilaginous line as far as the length of the flap (Fig. 68.1A). The incision then makes a
sharp turn around at the end of the flap, coming back anteriorly and parallel to the first incision along an
anterior vestibular line—fashioning a flap width of 0.5 to 0.75 cm (Fig. 68.1B).
As the columella is advanced forward, these bilateral chondromucosal flaps will ride forward with the tip and
swing medially into the membranous septal gap (Fig. 68.1C). The flaps come together between the
columella and the septum, with their cartilages touching and the lining facing out. Closure of the lateral
donor areas will lift the relatively long side walls for additional correction of the deformity (Fig. 68.1D and E).
Hanging Columella and Retracted Lateral Side Walls
By taking the excess of chondromucosal tissue from between and including various portions of the columella and
septum, this part of the deformity is corrected (Fig. 68.2B). Transposition of these flaps in a “wing spreading”
maneuver places both support and additional lining into the defect produced by lateral relaxing incisions inside
the vestibule parallel with the alar margins (Fig. 68.2C). Not only does this let the retracted alar rim down, but the
added support opens the airway and maintains the improved aperture (Fig. 68.2D and E).
SUMMARY
Nasal vestibular chondromucosal flaps can be taken from the lateral side walls to correct a retracted
columella and depressed nasal tip. Reverse chondromucosal flaps can be taken from the septum to correct
a hanging columella that is exaggerated by retracted lateral side walls. Unilateral defects also can be
corrected using this flap.
References
1. Millard DR Jr. The triad of columella deformities. Plast Reconstr Surg 1963;31:370.
2. Millard DR Jr. Secondary corrective rhinoplasty. Plast Reconstr Surg 1969;44:545.
3. Millard DR Jr. The versatility of a chondromucosal flap in the nasal vestibule. Plast Reconstr Surg
1972;50:580.

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Chapter 69
L-Shaped Septal Chondromucosal Flap
D. R. MILLARD JR.
EDITORIAL COMMENT
This is an attractive idea, but it is extremely difficult to execute and still retain an adequate blood supply to
the cartilage.
Nasal reconstruction requires the provision of support, as well as cover and lining (1). When the support
normally provided by the septum has been lost, an L-shaped septal chondromucosal flap usually can be
advanced from remaining septum. It can then be lifted out of the nasal cavity, so that its front prow rests on the
nasal spine area, and it can be fixed at this point (2).
FIGURE 69.1 The remaining septum is marked and cut as an L-shaped chondromucosal flap based superiorly.
The chisel is seen freeing the anterior portion of the flap from the vomerine groove. The broken line at the base
of the L (toward the dorsal tip of the nasal bones) is the area where the cartilage can be divided subperiosteally
if release is needed.
INDICATIONS
The septum is the most important normal nasal support of two-thirds of the distal bridge, the tip, and the
columella. When this portion of the septum has been lost by cancer ablation, trauma, burns, or infection,
new support must be supplied. Usually, this has been accomplished by free grafts of costal cartilage or iliac
bone after new lining and cover have been transported to the nasal defect.
In many cases, even though the actual effective bridge, tip, and columella support of the septum has been
lost, there is still enough septum hidden back in the nasal cavity. The remaining septum has thin but strong
cartilaginous support, and it is covered tenaciously with mucosa, which, of course, is ideal for reconstructing
the distal half of the nose.
FLAP DESIGN AND DIMENSIONS

The superior base of the L, as well as its right angle, is maintained at least 1 cm wide to ensure adequate
vascularity through the covering mucosa (Fig. 69.1).
FIGURE 69.2 The L-shaped chondromucosal flap has been advanced out of the nasal vestibule and fixed on the
nasal spine. The mucosa has been sutured to close off the cartilage posteriorly, and a split-thickness skin graft is
placed to cover the anterior raw area of the septum temporarily. This scaffold offers excellent support for
reconstruction of the nose.
OPERATIVE TECHNIQUE
If there is difficulty with rotation of the L component forward, careful subperichondrial division of a part or all of
the septal cartilage at the proximal base of the chondromucosal flap (broken line in Fig. 69.1) will facilitate its
deliverance out into the real world (Fig. 69.2).
The exposed cartilage of the underside of this flap is shaved back to allow closure of mucosa without tension, as
a protected compartment. The raw front of the septal L is covered temporarily with a split-thickness skin graft
(Fig. 69.2).
It is wise to advance this lined nasal framework and allow it to become established as a dependable scaffold for
1 month before cloaking it with the lining and cover of a nasal reconstruction.
SUMMARY
A septal chondromucosal flap can provide ideal support for a nasal reconstruction.
References
1. Millard DR Jr. Aesthetic reconstructive rhinoplasty. Clin Plast Surg 1981;8:169.
2. Millard DR Jr. Reconstructive rhinoplasty for the lower half of a nose. Plast Reconstr Surg 1974;53:133.

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Chapter 70
Internal Nasal Vestibular Skin-Mucosal Flaps
T. R. VECCHIONE
The columella is the cornerstone of naso-oral construction and is necessary for a pleasing balance. When it is
destroyed by infection, trauma, or disease, its absence becomes glaringly obvious (Fig. 70.1A). The successful
treatment of patients lacking the lower septum and columella with a simple one-stage flap is presented.
FIGURE 70.1 A,B: An 8-year-old boy with absent columella secondary to severe infection at age 4. The
columella, membranous septum, and 0.4 × 3.0 cm of cartilaginous septum were missing. C,D: The patient 2
years after local tissue columellar reconstruction.
INDICATIONS
The difficulty in reconstructing this subtle aesthetic unit has stimulated many elaborate operative techniques
requiring multiple stages (1). Various composite grafts from the ear and
lip have been described, but these are of benefit only in the partially deficient columella with sufficient
surrounding tissue present for composite graft take. These grafted tissues also were noted to shrink and
become “fibrotic lumps.”

FIGURE 70.2 A: The local skin-mucosal flaps are based just above the philtrum, extending out along the
nasal vestibule and then upward to include mucosa lining the lateral alar cartilage. B: When the two flaps
are brought together in the midline, they extend beyond the nasal tip. C: The flaps are sutured to the
dissected nasal tip. The flap donor sites heal by epithelialization and wound contracture. D: On close
inspection, the bucket-handle effect can be seen, but this is not readily recognized at conversational
distances.
The mucosa of the upper lip followed by a split-thickness skin graft has been used, but wound contracture
and fibrosis have detracted from the long-term results (2). A frontonasal flap based on the temporalis artery
(3) has been refined (4) by using a median frontal flap tunneled subcutaneously to bring a pedicle to the
columella. The versatile nasolabial flap has been transferred through the nasal mucosa passing between
the ala and triangular cartilages in a three-staged procedure (5). The centrally based upper lip flap and an
adjacent nasolabial flap have been used to reconstruct the columella in a one-stage procedure (6). The
price paid is a bearded columella and facial scars.
The internal nasal vestibular flap presented here eliminates any external scars in the flap donor site.
ANATOMY
This flap consists mainly of nasal vestibular skin, but it may include some mucosa. The circulation is of a
random-pattern type.
FLAP DESIGN AND DIMENSIONS
Bilateral skin-mucosal flaps are based on the nasal floor just superior to the philtrum and extend around the
nasal cupola. The flaps usually measure about 6 mm in width and extend parallel to the alar rim approximately 2
cm.
OPERATIVE TECHNIQUE
Once the vestibular lining is elevated off the lateral alar cartilage, the flaps are raised and rotated toward the
midline to reconstruct the columella (Fig. 70.2A). A small anteriorly based flap under the nasal tip is elevated,
providing a raw surface into which the distal tips of the flaps are inset. After the flaps are sutured, the nasal
airways are packed with petrolatum gauze. The flap donor site is allowed to close by epithelialization and wound
contracture.
CLINICAL RESULTS
The intact alar cartilage minimizes the distortion caused by contraction as the nasal vestibule
reepithelializes. Resurfacing the caudal edges of the reconstructed columella with a non-hair-bearing skin