Grabb’s Encyclopedia of Flaps Head and Neck

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Chapter 71
Multi-Island Free Radial Forearm Flap for Reconstruction of The
Nasal Lining
R. L. WALTON
EDITORIAL COMMENT
Total nose reconstruction has reached a level of spectacular development (1, 2, 3, 4), particularly with the
clinical examples demonstrated by Walton and Burget. Nasal lining is a most important step prior to the
placement of the cartilaginous framework and the overlying skin. The multi-island free radial forearm flap
demonstrated here provides the nasal lining quite well. Obviously, it requires a considerable amount of
planning.
The first stage for reconstruction of total and subtotal nasal defects is the microsurgical transfer and restoration
of the nasal lining and adjacent cheek and upper lip elements, using a multi-island free radial forearm flap. Two
months following microsurgical transfer of the nasal lining flap, nasal reconstruction proceeds with application of
a cartilage framework and a paramedian forehead flap.
FIGURE 71.1 Preoperative frontal view of subtotal nasal defect showing composite loss of nasal tip, columella,
alae, anterior septum, and vestibular lining.
INDICATIONS
Restoration of major nasal loss involving overlying skin and underlying nasal passages including support
and lining requires staged reconstruction. A microsurgical approach is used for restoration of the nasal
lining prior to external nasal cover reconstruction. Following defect evaluation and careful discussion with
the patient, the operative sequence is initiated (Figs. 71.1, 71.2, 71.3).
FLAP DESIGN AND DIMENSIONS

Preoperatively, an Allen test is performed to ensure adequate hand perfusion via the ulnar vascular pedicle. The
nasal site is dissected first, with excision of the remnant scar and any skin grafts, to recreate the original defect
(Fig. 71.4). Templates of the missing vestibular and adjacent lip and cheek defects are made of foil from surgical
suture packets and then transferred to the forearm, where they are aligned to the radial vascular pedicle as
separate islands. The radial side of the flaps is positioned to overlap the vascular pedicle by no more than 5 mm,
so as to place the pedicle out of harm's way during subsequent procedures. For the vestibular lining element, we
have found it helpful to orient the vascular pedicle at the cephalic edge, so as to allow unsullied access to the
nasal tip and vestibule for placement of the supporting cartilage grafts and for sculpting (Fig. 71.5).
FIGURE 71.2 Preoperative three-quarter view depicting subtotal nasal defect.
FIGURE 71.3 Preoperative lateral view depicting subtotal nasal defect.

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FIGURE 71.4 Preparation of the nasal site. Contracted scar has been removed, and the wound and adjacent
nasal elements are repositioned anatomically.
FIGURE 71.5 Templates of the missing nasal lining elements are aligned to the radial vascular pedicle. In this
case the multi-island flap will restore the nasal vestibular lining, the floor, and columellar elements.
Care is taken to provide sufficient skin island separation, to accommodate the three-dimensional positioning of
these elements at the nasal site. For this purpose, in the planning stage, we have found it useful to attach each
of the island templates with strips of paper tape, to duplicate the radial vascular pedicle, and then to determine
the best three-dimensional configuration of the islands that duplicates the missing anatomy without kinking the
vascular pedicle. The fine vascular perforators from the radial pedicle to the overlying skin islands cannot be
identified via Doppler or contrast angiography preoperatively, thereby calling for a flap design and configuration
based largely on confidence in the vascular anatomy. The distribution of these vessels in the distal forearm has
proved to be fairly consistent in our experience, with adequate physiologic flow provided in more than 100
consecutive multi-island flaps without any loss.
OPERATIVE TECHNIQUE
The proximal pedicle should be at least 8 to 10 cm in length, to allow it to span the distance from the nasal defect
site to the facial artery and vein at the inferior border of the mandible. This distance is measured intraoperatively
so that adequate pedicle length is provided. A 2-cm incision is made just below and parallel to the inferior
mandibular border at the site of the facial vessels. The platysmal fibers are dissected apart longitudinally, to

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expose the facial artery and vein. The marginal branch of the facial nerve is identified and protected. A
submuscular aponeurotic system (SMAS) tunnel spanning the nasal site and the facial vessel site is then bluntly
dissected with progressive surgical dilators.
FIGURE 71.6 The radial forearm flap has been dissected above the level of the deep forearm fascia and
separated into three separate islands. Following debulking of the flap islands, the flap will be transferred to the
nasal site, where it is revascularized to the facial vessels.
The one- to three-island radial forearm flap is dissected under tourniquet control (Fig. 71.6). Each island is
dissected from its ulnar margin above the level of the forearm fascia to the tendon of the flexor carpi radialis.
Here, the dissection transitions to the subfascial plane to the radial vascular pedicle. On the radial side of the
flap, the dissection proceeds through the subcutaneous tissue, with care taken to identify and protect the dorsal
sensory branches of the radial nerve. Occasionally, one or two small branches of the radial sensory nerve may
be found entering the radial forearm flap. These are divided, and the proximal stumps are buried in the volar
forearm musculature, to avoid painful neuroma formation.
The radial artery and its venae comitantes are dissected distal to the last skin island in the chain, ligated with
fine polypropylene sutures, and divided. The dissection then proceeds deep to the radial vascular pedicle, where
several large
branches will be seen entering the dorsal musculature. These are ligated with fine monofilament sutures and
divided. Using operative magnification, dissection of the island flaps is then performed, with identification and
preservation of the multiple small filamentous branches from the radial vascular pedicle to each island. Despite
their very small size, preservation of these branches is paramount to successful flap perfusion. The vascular
pedicle is then dissected proximally to its appropriate length, with ligation and division of its multiple forearm
muscular branches (Fig. 71.6).
The flap is allowed to perfuse at the forearm site for 30 minutes prior to transfer. During this time, the operating
microscope is used to debulk selected elements of the flap (especially the vestibular lining element). This is
accomplished by incising the fibrous interstitium between the fat lobules and gently suctioning the fat away
directly by a process dubbed “lipoplucksion.” We have found this to be a very effective technique for performing
the initial debulking of the acute flap, without compromising its blood supply.
After the flap pedicle is divided, the flap is transferred to the nasal site, where it is temporarily secured with 4-0
silk sutures. The vascular pedicle is gently directed through the subcutaneous tunnel in the cheek, using a 32 to
36 French-size chest tube guide lubricated with a continuous lactated Ringer solution drip, to avoid avulsion of
any vascular branch ligatures or inadvertent twisting. The vascular repairs are performed end-to-end to the facial
artery and vein. Although no systemic anticoagulation is used, we routinely employ high-concentration heparin
irrigation (50,000 units heparin per 100 mL lactated Ringer solution) while performing the vascular anastomoses.

Aspirin (81 mg) is also administered intraoperatively and for 21 days postoperatively for its prostacyclin and
antiplatelet effects.
Following reestablishment of vascular inflow, the flap is inset anatomically with fine sutures. To avoid contraction
of the nasal vestibular lining elements, we have found it useful to brace the flaps with small grafts of cadaver
allograft cartilage placed in the midline and along the caudal edge of the vestibule and secured with 6-0 PDS
suture prior to skin grafting (Fig. 71.7). When placed over the supporting cartilage allografts, the take of the full-
thickness skin graft is not compromised, owing to its excellent capacity for bridging. The undersurface of the
vestibular element, which now lies externally, is closed with a full-thickness skin graft from the inguinal region
(Figs. 71.8, 71.8, 71.9, 71.10). When the grafted area is large, a fine suction drain, fashioned from a 22-gauge
butterfly intravenous needle, is placed beneath the skin graft, to facilitate graft adherence and to promote serous
drainage. A simple Xeroform/muropuracin dressing is applied to the grafted vestibular element. No internal nasal
packing or stents are employed.
FIGURE 71.7 Frontal view of the radial forearm flap inset prior to placement of the full-thickness skin graft. Note
position of the vascular pedicle at the cranial edge of the flap. Cadaver cartilage allograft has been used to stent
the vestibular lining element to stifle its shrinkage in the interim prior to placement of the definitive cartilage
framework and the paramedian forehead flap. The cartilage allografts are secured with fine absorbable
monofilament sutures. Skin graft “take” over the cartilage grafts occurs via bridging.
FIGURE 71.8 Inset of the radial forearm flap (submental view). The separate flap islands have been articulated
to duplicate the three-dimensional anatomy of the missing elements.
The forearm donor site is closed with a full-thickness skin graft from the inguinal region for optimal pliability and
cosmetic appearance. The graft is secured with a stent dressing, and the forearm and hand are immobilized in a
bulky dressing.

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The graft stent is removed at 7 days postoperatively, and the forearm is wrapped in an elastic compression
sleeve for 6 weeks. Graded, active use of the hand is allowed at 10 days postoperatively.
FIGURE 71.9 Inset of the radial forearm flap (frontal view). The undersurface of the vestibular lining flap element
is temporarily covered with a full-thickness graft from the inguinal region.
FIGURE 71.10 Inset of the radial forearm flap (lateral view).
When fully healed and edema has subsided, the external skin graft on the nose is removed, an autologous rib
cartilage nasal framework is constructed, and a paramedian forehead flap is transferred for restoration of the
external nasal cover.
SUMMARY
The radial forearm flap is an excellent option for use in restoration of nasal lining and adjacent cheek and lip
defects for total and subtotal nasal reconstruction. The flap anatomy is consistent, allowing for configuration
into multiple islands that can be articulated to duplicate the three-dimensional nasal lining anatomy. Flap
dissection is superficial to the deep forearm fascia, using the venae comitantes for venous outflow.
Revascularization is via the facial artery and vein. Cadaver allograft cartilage is used to stent the flap
elements to prevent their shrinkage prior to definitive construction of an autologous cartilage framework.

References
1. Walton RL, Burget GC, Beahm EK: Microsurgical reconstruction of the nasal lining. Plast Reconstr Surg
2005;115(7):1812.
2. Burget GC, Walton RL: Optimal use of microvascular free flaps, cartilage grafts, and a paramedian
forehead flap for aesthetic reconstruction of the nose and adjacent facial units. Plast Reconstr Surg
2007;120(5):1171.
3. Beahm EK, Walton RL: Nasal reconstruction. In: Butler CE, Fine NA, Eds., Principles of cancer
reconstructive surgery. New York: Springer, 2006.
4. Walton RL, Beahm EK, Burget GC: Nasal reconstruction. In: Grotting JC, Ed., Reoperative aesthetic and
reconstructive plastic surgery, 2nd Ed. St. Louis: Quality Medical Publishing, 2007;705-758.

Chapter 72
Forked Flap
D. R. MILLARD JR.
EDITORIAL COMMENT
Columellar lengthening is obtained by adding tissue from the lip. This is exemplified in an adult male who
has undergone the procedure as a child and has to shave under his nose. It is not clear whether or not the
patient with a bilateral cleft lip has an actual shortage of skin at the level of the columella or if everything is
pulled down because of the distortion of the tissues. An alternative approach would be to stretch out the
pulled down columella by a bone graft that will hold the tip of the nose up, as does the spoke of a tent.
The forked flap was initially designed to lengthen a short columella in a secondary bilateral cleft. The forked flap
is taken out of the lip continuous with the present short columella. This approach not only lengthens the
columella, but also allows revision of bilateral lip scars and reduces the wide prolabium to a more natural philtrum
dimension (1, 2, 3, 4).
INDICATIONS
The forked-flap technique is of value in bilateral cleft patients when the columella is short and the upper lip
is not tighter than the lower lip (Fig. 72.1). The procedure also has been found of value in primary bilateral
cleft patients when the prolabium is extremely diminutive (Fig. 72.2), as well as when the prolabium is wide
enough in the primary deformity to spare a forked flap from its sides and still leave enough central portion
for a philtrum (Fig. 72.3).
FIGURE 72.1 A: Short columella and wide prolabium. Note that the forked flaps include the old bilateral
cleft lip scars. Note also that the membranous septal incision is extended over the nasal tip, as indicated by
the broken line. B: The forked flaps are sutured together and advanced along the septum. They are
sutured together in front and then tubed behind to create a column. The distal tips of the fork are left free to
spread at the columella base. The alar bases, with their tips denuded of epithelium, are sutured together at
the nasal spine in a cinching procedure. C: The ends of the forked flaps are sutured to the alar bases to
form the nostril sills. The lateral lip elements are sutured to the sides of the reduced prolabium, and the
lateral mucocutaneous flaps are advanced to the midline below the prolabium to create a better cupid's bow
and tubercle.

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In the unilateral cleft lip, the cleft side shortness of the columella is lengthened by flap C in the rotation-
advancement operation. Flap C acts as a one-sided forked flap.
OPERATIVE TECHNIQUE
Short Columella and Wide Prolabium
This problem can be improved by a forked flap that includes the old bilateral cleft lip scars (Fig. 72.1).
FIGURE 72.2 A: Complete bilateral cleft lip with small prolabium. B: Prolabium and lateral lip elements are
marked for incisions to create bilateral adhesion. C: Prolabium vermilion is turned from the sides for nasal
closure and from the inferior border to freshen the edge. The lateral mucocutaneous flaps are used to create a
cupid's bow along the inferior edge of the prolabium. D: After the adhesion is completed, the lateral muscle pull
will stretch the prolabium. E: At 1 year, the prolabium is stretched enough to spare a forked flap. F: The forked
flap and membranous septal incision are marked. G: The forked flap is sutured and advanced along the septum,
the
Complete Bilateral Cleft Lip with Small Prolabium
The lateral elements are merely attached to the sides of the tiny prolabium in an adhesion procedure, and within
a year, the muscle pull will have stretched the prolabium wide enough to give up a forked flap. This flap can then
be taken out of the lip and either banked in a whisker position below the alar bases or advanced into the

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columella (Fig. 72.2).
Complete Bilateral Cleft Lip with Wide Prolabium
If the prolabium is wide enough in the primary deformity to spare a forked flap from its sides and still leave
enough central portion for a philtrum, then forks are banked in the whisker position. At the preschool age of 5
years or as soon as the premaxilla is in reasonably good alignment with the lateral maxilla and fixed, the forks are
shifted out of the whisker position and advanced into the columella to release the depressed nasal tip (Fig. 72.3).
There are several points in the technique that may be helpful in achieving a natural effect: First, when cutting the
forks in secondary cases, take as much prolabium on each side as necessary to shape it as a philtrum, and
include the lip scars. Second, release the present short columella with a membranous septal incision that is
carried well over the tip of the septum to ensure adequate release. Third, suture the skin of the forks together in
front with 6-0 suture. Then roll this double flap into a column with subcutaneous sutures of 5-0 chromic catgut.
Advance the new columella column along the membranous septum and fix it with 4-0 chromic catgut. Fourth,
leave the distal ends of the forked flap free to spread sideways as the medial feet of the columella to form part of
the nostril sill when sutured to the alar bases. Finally, subsequent septal
or auricular cartilage grafts can be used in the columella to improve the nasal tip support, which is severely
lacking owing to the absence of septal projection in the tip in patients with bilateral clefts.

FIGURE 72.3 A: Complete bilateral cleft lip with wide prolabium. The forked flaps are marked on the sides of the
prolabium. The lateral lip edges are incised and the alar bases released. B: The lateral lip elements are
advanced to the sides of the prolabium with muscle advancement into the prolabium. The lateral mucocutaneous
flaps are used to overlap the turndown of the inferior prolabium vermilion. C: The forked flaps are banked in the
whisker position under the alar bases. D: Lip complete with the forked flaps in the banked position. E: At about 5
years, the forked flap is taken out of the whisker position with no need to disturb the lip. The continuations of the
forked flap and membranous septal incision have been marked with a broken line. F: The forked flap is being
advanced into the columella, and the alar bases are being cinched together. G: The columella is lengthened and
the alar bases and nostril sill correction is achieved without the need to go back into the lip and spoil the good
scars of infancy.
SUMMARY
In certain cleft lip deformities, forked flaps can be used to lengthen the columella both primarily and
secondarily.
References
1. Millard DR Jr. Columella lengthening by a forked flap. Plast Reconstr Surg 1958;22:454.
2. Millard DR Jr. Cleft Craft, Vol. II. Boston: Little, Brown, 1977;359-374, 491-538.
3. Millard DR Jr. Closure of bilateral cleft lip and elongation of columella by two operations in infancy. Plast
Reconstr Surg 1971;47:324.
4. Millard DR Jr. Earlier correction of the unilateral cleft lip nose. Plast Reconstr Surg 1983;70:65.

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Chapter 73
Bilateral Cheek Island Skin Flaps
I. KAPLAN
M. BEN-BASSAT
EDITORIAL COMMENT
The procedure described shows an excellent reconstruction of the columella. Location of the discrete artery
may be very difficult; however, this procedure should be successful even if subcutaneous pedicles are used
as an alternative source of blood supply.
Many procedures for reconstruction of the columella have been described, but we have found that bilateral
cheek island skin flaps have provided gratifying results (1).
INDICATIONS
These flaps are useful in patients in whom the columella alone is missing or in whom there is also a
concomitant defect of the upper lip.
FIGURE 73.1 A: Absence of the nasal columella. B: Bilateral island skin flaps are based on the anterior
facial artery, which can be localized with a Doppler probe. C: The island flaps are tunneled through the
upper lip and sutured together to form the columella. D: The flap donor-site wounds are closed by suturing
the wound edges. (From Kaplan, ref. 1, with permission.)
ANATOMY
Bilateral inferiorly based skin flaps are taken from the cheek area. The circulation of these flaps is based on the
anterior facial vessels (Fig. 73.1B).
OPERATIVE TECHNIQUE
The flaps are raised as shown in Figure 73.1B. A rectangular skin paddle is carried on a subcutaneous pedicle.
After a tunnel

is formed under the skin of the upper lip, the flap is transferred to the defect. The two flaps are then sutured
together to form the columella. The donor sites can usually be closed primarily.
FIGURE 73.2 A: Defect of the columella and the cephalad portion of the upper lip following radical excision of a
skin cancer. B: Profile view at completion of the reconstruction of the columella and adjacent lip with bilateral
cheek flaps. Note the sutured donor site of one of the flaps. C: Pyramidal view of the columella 3 weeks
postoperatively. (From Kaplan, ref. 1, with permission.)
If there is also a defect of the upper lip, it is repaired by including the skin from the base to the tip of the flap
rather than by just using a skin paddle (Fig. 73.2).
SUMMARY
Bilateral cheek island skin flaps can be used to reconstruct the columella. These flaps are especially useful
when there is an associated defect of the upper lip.
Reference
1. Kaplan I. Reconstruction of columella. Br J Plast Surg 1972;25:37.

Chapter 74
Labial Mucosal Flaps for Reconstruction of The Columella
J. R. LEWIS JR.
EDITORIAL COMMENT
The use of mucosal flaps to reconstruct the columella has two obvious disadvantages: (1) the lack of color
match, and (2) the tendency of the mucosa to dry and crust. Both disadvantages are partly corrected by
resurfacing of the mucosa with a skin graft.
A flap or flaps from the labial mucosa can be pulled through the lip at the proposed columella base and inserted
into the nasal tip for reconstruction of the columella. This is a procedure that has been used on a number of
occasions by the author.
INDICATIONS
Mucosal flaps may be used to supply bulk from the base of the lip up to the tip of the nose to form the
columella. However, this gives a pink mucosal appearance that generally is secondarily grafted with a full-
thickness graft from the back of the ear to give the desired skin color and texture.
The mucosal flap is an undesirable first choice unless there is no tissue available in the immediate area to
use as a direct flap. This would be the case when there has been extensive surgery in the nasolabial areas
for malignancy or injury or when there has been extensive radiation to the cheeks. However, in such
instances, the mucosal flaps themselves may have a precarious blood supply.
ANATOMY
The anatomic basis of the labial mucosal flap that extends outward in the cheek and is based farther laterally
would be the superior labial artery. The superior labial vein would complete the circulatory exchange. For
bilateral labial flaps taken on the medial aspect of the lip, the circulation is more precarious and would depend on
branches of the superior labial artery and a septal branch, unless this had been interrupted. The superior labial
artery anastomoses with its counterpart on the opposite side, with the lateral nasal branches of the facial artery,
and with the septal branch of the sphenopalatine artery. If the septum has not been resected with the columella
for malignancy or has not been injured by trauma, the sphenopalatine artery may be used to give some
additional circulation into this flap.
FLAP DESIGN AND DIMENSIONS
The flap based medially is a reverse flap (Fig. 74.1A). When using two such flaps brought together through a
single opening at the base of the lip at the proposed base of the columella, they are sutured lightly together and
brought up to the underside of the nasal tip (Fig. 74.1B). As with reverse flaps of any sort, circulation is more
precarious and the length-to-width ratio is usually greater than ideal. One might wish to delay these flaps once or
twice to ensure better circulation, although the author has accomplished direct transfer of these flaps in one
stage.

FIGURE 74.1 A: Diagram of a superiorly based nasolabial flap. B: Elevation of the flap. C: Donor-site closure
and transfer of the flap to the columellar defect. D: Detachment of the carrier portion of the flap 3 weeks later.
(From Paletta and Van Norman, ref. 7, with permission.)
FIGURE 74.2 A: Patient who has had a resection of the whole septum, a part of the base of the nose, and the
whole columella for malignancy. B: Labial flaps being pulled through the base of the upper lip, to reconstruct the
columella. Skin color to the columella is supplied by a secondary skin graft, since the mucosal flaps would give a
pink, shiny appearance to the columella.
A similar type of flap may be based more laterally on the labial branch of the facial artery. Such a flap would be
brought upward and laterally with its mucosa and submucosa from inside the cheek and then through the base of
the lip in a fashion similar to the flaps described above.
If the flap is not too long in relation to its width (more than 3:1), and if the surgical outlining of the flap has been
gentle and careful, one generally has enough vascular supply to salvage the flap. Delaying the flaps, of course,
makes the circulation more secure.
OPERATIVE TECHNIQUE
Generally, a short flap can be taken directly, by leaving a thick base for circulation into the flap. The venous
return is likely to be satisfactory, since the patient lying on his or her back would naturally have good dependent
drainage from the tip to the nose toward the lip. To be more secure, one could delay the flaps in the usual
fashion, probably as a two-delay procedure, then bring the two flaps from either side of the lip toward the center,

where they are based, and bring them out together through the base of the lip to the tip of the nose. Usually,
these flaps do not have to be particularly long, but they should not be under tension or constricted by the
opening through the lip skin.
Skin from the lip and from inside the nose may be turned onto the pedicle to give a better color match to the
anterior aspect of the columella if this skin is available (Fig. 74.2). Also, an inlay skin graft may be used at a
delay procedure to give skin cover. A conchal cartilage graft is usually inserted later for support and contour.
SUMMARY
A satisfactory columella can be constructed from labial mucosal flaps either from the lateral portion of the lip
based on the labial branch of the facial artery or from the central portion of the lip as a reverse flap if they
are properly delayed. Reverse mucosal flaps are not, however, the first choice for reconstruction of the
columella.

Chapter 75
Nasolabial Skin Flap for Columellar Reconstruction
C. PALETTA
F. X. PALETTA SR.
Reconstruction of the nasal columella using a variety of techniques including composite grafts and skin flaps
have been described. Total columellar reconstruction requires a large volume of soft tissue that can be obtained
through the use of an adjacent skin flap. A technique that is immediate, has a good color match, takes a small
amount of time, and results in minimal scarring is the nasolabial flap.
INDICATIONS
Composite grafts from the outer helix of the ear have been used in columellar reconstruction, but they are
best used for partial defects (1, 2, 3). Composite grafts are also limited because the tissue bed for
columellar reconstruction is usually scarred or absent, thereby compromising the availability of a well-
vascularized bed for adequate composite graft take. Various flaps have been described to lengthen the
columella, especially in the bilateral cleft lip nasal deformity patient (4, 5, 6). When there is a complete loss
of the columella, however, with exposure of the nasal septum, it is necessary to use a skin flap.
Tubed pedicle flaps from the neck and arm have been used successfully in the past. However, multiple
stages are required to obtain the final result, and the flaps from these staged procedures tend to remain too
thick and bulky in this region. The forehead flap is an excellent choice in total and partial nasal
reconstruction, and it can also be useful in reconstruction of the columella. However, when the only defect
is in the columella, the forehead flap is not the best first choice because of the distance of the flap from the
defect and the potential wasted portion of the flap necessary in the transfer. The most accessible region for
reconstruction of the columella alone is the nasolabial area (7). It provides an abundant amount of adjacent
tissue with a good color match, and can easily be done under local anesthesia.
ANATOMY
See Chapter 40.
FLAP DESIGN AND DIMENSIONS
For coverage of the columellar region, a long nasolabial flap is preferred. The flap must curve around the
adjacent alar base to reach its final destination. Because of this, the base of the pedicle should be 2 to 2.5 cm in
width (Fig. 75.1). If possible in male patients, it may be advisable to base the pedicle inferiorly in order to avoid
transferring hair-bearing skin to the newly constructed columella. If it is not possible to base this flap inferiorly
due to prior scarring or if it is not preferable for any other reason, the hair-bearing portion of the nasolabial flap to
be transferred to the columella should initially be replaced by a full-thickness skin graft. This graft should be
taken either from the postauricular or supraclavicular region.
OPERATIVE TECHNIQUE
Design and elevation of the nasolabial flap for columellar reconstruction can easily be done under local
anesthesia. When based superiorly, the nasolabial flap is elevated without delay in the nasolabial groove,
extending down to the inferior border of the mandible. The plane of dissection is just beneath the subcutaneous

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fat of the flap, superficial to
the underlying facial musculature. The neighboring tissue on the cheek is widely undermined for closure of the
donor site in the nasolabial fold.
FIGURE 75.1 A: Diagram of a superiorly based nasolabial flap. B: Elevation of the flap. C: Donor-site closure
and transfer of the flap to the columellar defect. D: Detachment of the carrier portion of the flap 3 weeks later.
(From Paletta and Van Norman, ref. 7, with permission.)
FIGURE 75.2 A: A 62-year-old man with a basal cell carcinoma of the columella, nasal septum, and left nostril
floor. B: Frontal view of the result of columella reconstruction with a nasolabial skin flap and a cartilage graft
inserted secondarily. C: Oblique view of the final result.
When the tip of the nasolabial flap is transferred and inset, it is sutured to the mucous membrane of the
remaining septum. An absorbable suture material such as 5-0 chromic catgut is used for the mucuous
membrane. This mucous membrane must be carefully elevated off the septum for approximately 2 mm to allow
for suture placement. After the tip of the flap has been aligned with the mucous membrane, the flap is rotated and
inset to the appropriate segments on the nasal tip and upper lip. The flap is sutured to these adjacent points with
a nonabsorbable suture such a 5-0 nylon or silk. Occasionally, when wide resection has been necessary to
remove a cancer totally, the upper lip may need to be elevated in order to inset the flap to achieve complete
closure of the defect. Under normal circumstances, upper lip skin elevation is to be avoided as it is not a fixed

structure and this will lead to distortion of the upper lip.
da Silva (8) modified the classical superiorly based nasolabial flap by tunneling the flap transnasally for
columellar reconstruction. Division of the flap was then performed at a second stage in 2 to 3 weeks. Kaplan (9)
described a modification of the pedicled nasolabial flap. In one stage, he has used bilateral inferiorly based
island nasolabial flaps for columellar reconstruction. This avoids a dog-ear and a second-stage procedure. Yanai
et al. (10) further modified Kaplan's island technique by basing his nasolabial flaps superiorly.
When designed as a pedicle flap, the nasolabial flap can be detached at between 10 and 21 days. The
remaining flap can be tailored and reinserted into the cheek. In patients with a lot of fatty tissue in this region of
the face, defatting may be required to establish a smooth nasolabial line scar. A cartilage graft either from the
septum or ear may be inserted at a later date if support is required (Fig. 75.2).
SUMMARY
When a nasal defect consists of total columellar loss, the nasolabial flap provides an excellent means of
reconstruction.
References
1. Meade RJ. Composite ear grafts for reconstruction of the columella. Plast Reconstr Surg 1959;23:134.
2. Pegram M. Repair of congenital short columella. Plast Reconstr Surg 1954;14:305.
3. Pelliciari D. Columella and nasal tip reconstruction using multiple composite free grafts. Plast Reconstr
Surg 1949;4:8.
4. Straith CL. Elongation of the nasal columella. Plast Reconstr Surg 1946;1:79.
5. Marcks KN, Trevaskis AC, Payne NJ. Elongation of columella by flap transfer and Z-plasty. Plast Reconstr
Surg 1957;20:466.
6. Millard DR. Columellar lengthening by a forked flap. Plast Reconstr Surg 1958;22:454.
7. Paletta FX, Van Norman RT. Total reconstruction of the columella. Plast Reconstr Surg 1962;30:322.
8. da Silva G. A new method of reconstructing the columella with a nasolabial flap. Plast Reconstr Surg
1964;34:63.
9. Kaplan I. Reconstruction of the columella. Br J Plast Surg 1972;25:37.
10. Yanai A, Nagata S, Tanaka H. Reconstruction of the columella with bilateral nasolabial flaps. Plast
Reconstr Surg 1986;77:129.

Chapter 76
Bipedicled Nasal Septal Mucosal Flaps
D. N. F. FAIRBANKS
G. R. FAIRBANKS
Medical folklore suggests nose picking to be a common cause of septal perforations, but septal operations
appear to be the far more frequent offender at present. Intranasal cryosurgery and cautery for epistaxis, when
performed bilaterally and simultaneously in corresponding areas, also can lead to perforations. Nasal septal
abscess, which usually forms after untreated posttraumatic septal hematoma, syphilis, tuberculosis, Wegener's
granulomatosis, and cocaine abuse, also can cause perforations.
A combined technique of bipedicled mucosal advancement flaps fortified with a temporalis fascia autograft is a
good method of closing perforations (1).
INDICATIONS
The perforated nasal septum vexes both the patient and the physician (Fig. 76.1). It commonly causes
intranasal crusting and epistaxis, and it occasionally causes whistling, particularly when the perforation is
small. While these may be minor annoyances for some patients, for others they are major handicaps.
The nonoperative treatment of nasal septal perforations will not be discussed in this chapter (2, 3). Surgical
techniques reported in the literature for closure are varied and ingenious. However, advancement of viable
tissue into a hole is indeed a difficult surgical challenge, one plagued by slough and reperforation often
several months or years postoperatively. Many surgeons are still pessimistic regarding the probability of
successful surgical closure.
Septal perforations can be closed with bipedicled advancement flaps of nasal mucosa designed to maximize
the vascular supply of the septum (Fig. 76.2). The repair is then fortified by the submucosal insertion of a
temporalis fascial or pericranial autograft. The graft increases the success of the repair, even when
complete mucosal closure is difficult.
ANATOMY
A bipedicled flap of septal mucosa is designed so that the incisions along the nasal dorsum and nasal floor run
parallel to the blood supply (4). The arteries that supply these flaps, through interconnecting anastomoses, are
the anterior ethmoid, the posterior ethmoid, and the sphenopalatine (Fig. 76.2).

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FIGURE 76.1 Cross section of the nose through a perforation in the cartilaginous septum. (From Fairbanks, ref.
5, with permission.)
FIGURE 76.2 Arterial supply of the nasal septum. (From Gollom, ref. 4, with permission.)
FIGURE 76.3 Donor site for temporalis fascial autografts. [From Fairbanks (5), with permission.]
OPERATIVE TECHNIQUE
A graft of temporalis fascia (aponeurosis) is obtained from above the ear of the patient (Fig. 76.3). If the fascia is
of poor quality, or if a thicker graft is desired, the dissection is carried through the temporalis muscle to the
pericranium, which can be used for the graft. Alternate donor material would be fascia lata or fascia from the
external oblique muscle. The graft should be 2 cm larger in diameter than the perforation it is designed to cover.
The septal mucoperichondrium and mucoperiosteum are elevated on one side through a contralateral columellar
incision (Fig. 76.4A). The perforation is incised circumferentially. One often finds the mucosa from opposing
sides adhering together, since considerably more cartilage may be absent than the size of the perforation
suggested. Tedious and patient dissection is required to incise the edges of the perforation without enlarging it.
The upper flap yields a considerable amount of redundant mucosa and is easy to advance; the lower flap is more
difficult to advance. Its relaxing incision should be continued approximately 2 cm behind the posterior edge of the
perforation at the angle where the vomer meets the nasal floor. From this point, it can be curved out onto the
nasal floor, even beneath the inferior turbinate, to obtain extra mucosa, but it must then be curved back toward
the septum anteriorly, where it ends in the floor of the nasal vestibule. The flaps should be made so as to
advance and cover the perforation with no tension on the fragile leading edges.

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FIGURE 76.4 A: Elevation of mucosa from the left side of the septum around the perforation through a
contralateral columellar incision. B: View of the elevated left septal mucosa on cross section. (From Fairbanks,
ref. 5, with permission.)
On the contralateral side it may not be essential to raise another flap if closure on the first side is complete.
However, bilateral flap closure will accelerate healing time and is therefore advisable. Nevertheless, only a lower
flap should be developed on the second side, since advancement of an upper flap would result in cartilage being
laid bare on both sides, and a new perforation would surely develop (Fig. 76.5).
Figure 76.6 depicts a lower flap designed similarly to the one on the opposite side, except that anteriorly the
incision joins the columellar incision. Sometimes the lower flap can be advanced to cover the perforation
completely. When it cannot, it should be made to cover at least any areas that were not completely covered on
the opposite side, so that the graft, when it is inserted, will become vascularized from one side or the other.
Mucosal edges are brought together without tension and sutured with 5-0 ophthalmic plain catgut. A small piece
of metal foil from the suture wrapper is temporarily inserted between the flaps of the right and left sides before
the suturing, so that opposing flaps are not inadvertently sutured to each other. Then the graft, trimmed to size,
is inserted through the columellar incision between opposing mucosal flaps (Fig. 76.7) so as to overlap the
cartilaginous defect by a centimeter on all sides. The columellar incision is closed, and the nasal cavities are
packed lightly with gauze packs impregnated with antibiotic ointment. The packs are left in place for 1 week.
When the nose is unpacked, any areas of the graft that were left uncovered will appear white and stringy, and
crusts will form. They should not be debrided, for the graft gradually revascularizes and forms a sturdy base for
mucosal epithelialization.
FIGURE 76.5 A: Mucosal closure with bipedicled flaps on the left side. B: View of the closure on cross section.

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(From Fairbanks, ref. 5, with permission.)
FIGURE 76.6 A: Mucosal closure with a bipedicled flap from below only on the right side. B: The right-sided
mucosal closure on cross section. (From Fairbanks, ref. 5, with permission.)
FIGURE 76.7 A: Completed closure with the fascial graft inserted under the left septal flaps. B: The final closure
on cross section. (From Fairbanks, ref. 5, with permission.)
CLINICAL RESULTS
This combined technique has yielded more than a 90% success rate in the authors' experience with 35
patients over a 10-year period.
SUMMARY
A bipedicled nasal mucosal flap to close septal perforations has been described. This flap is augmented by
a temporalis fascial autograft.
References
1. Fairbanks DNF, Fairbanks GR. Surgical management of large nasal septum perforations. Br J Plast Surg
1971;24:382.

2. Kern EB, Facer GW, McDonald TJ, et al. Closure of nasal septal perforations with a Silastic button. ORL
Digest 1977;39:9.
3. Fairbanks DNF, Fairbanks GR. Nasal septal perforations: prevention and management. Ann Plast Surg
1980;5:452.
4. Gollom J. Perforation of the nasal septum. Arch Otolaryngol 1968;88:518.
5. Fairbanks DNF. Closure of nasal septal perforations. Arch Otolaryngol 1980;106:509-513.

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Chapter 77
Inferior Turbinate Flap for Closure of Septal Perforations
H. D. VUYK
R. J. J. VERSLUIS
EDITORIAL COMMENT
Septal perforations are most difficult to close. The use of buccal mucosa or skin usually gives unsatisfactory
results; consequently, the use of similar types of mucosa from the inferior turbinate is most advantageous.
The limiting factor, as the authors indicate, is that two procedures may be required and there is only a small
amount of tissue that can be mobilized safely.
The inferior turbinate flap, although not always successful, can be used to repair symptomatic septal
perforations; specific symptoms such as epistaxis, whistling, and frontal headache appear to improve, even after
partial closure.
INDICATIONS
Several methods for surgical closure of perforations of the nasal septum have been proposed (1, 2, 3, 4, 5,
6). The inferior turbinate flap was introduced in 1980 by Masing and colleagues (1). Their concept was
based on the assumption that symptoms such as crusting, obstruction, bleeding, and whistling are caused
by the desiccating effects of the inspiratory airflow on the posterior rim of the perforation. Consequently, this
technique aims at protection of the posterior rim from inspiratory airflow, not necessarily at complete closure
of the perforation itself.
ANATOMY
The size of septal perforations in our series of 35 patients ranged from less than 0.5 cm to larger than 1.5 cm.
The anterior margin of the perforation was localized in the vestibular or nasal-valve area in most patients and at
the level of the anterior border of the inferior turbinate in a few patients. Apart from the symptomatic anterior
perforation, only two patients had a second perforation more posteriorly that did not need treatment.
OPERATIVE TECHNIQUE
The procedure involves two stages (Fig. 77.1). In the first stage, a flap of the lateral nasal wall, which is centered
around the inferior turbinate and includes vestibular skin, is raised and sutured anteriorly to the anterior, inferior,
and superior edges of the septal perforation (Fig. 77.2). In the second stage,
the pedicle of the flap is sectioned posteriorly, rotated into the perforation, and sutured in place to the posterior
rim to close the defect. Silastic sheets are used to prevent adhesions with the lateral nasal wall, although not
always successfully.

FIGURE 77.1 Diagram of the two-stage (A,B) principle of closure of a nasal septal perforation with an inferior
turbinate flap. (From Vuyk and Versluis, ref. 6, with permission.)
FIGURE 77.2 A: Schematic development of an inferior turbinate flap. Alotomy is outlined for demonstration
purposes. B: Diagram of inferior turbinate flap sutured to the mucosa on the opposite side of the septum
anteriorly, inferiorly, and superiorly. Division of the pedicle of the flap posteriorly requires a second stage. (From
Masing et al., ref. 1, with permission.)
Some variations include a lateral alotomy for better exposure, an anterior mucosal flap, a retroauricular full-
thickness graft, and a concomitant septal correction for a posterior deviation. A small anterior-superior-based
septal rotation flap may be used to cover the anterior part of the inferior turbinate flap in the first stage. The
mucosal defect on the lateral nasal wall may be covered with a full-thickness graft from the retroauricular skin.
Fibrin glue in the first stage is helpful in fixing the flap and in its eventual coverage.
CLINICAL RESULTS
The procedure has the advantage of not disturbing the blood supply of the cartilage of the nose; however,
multiple stages are involved, and sequelae may be difficult to treat. Although the perforation was closed by
almost two thirds or more in 50% of the cases, postoperative scarring caused nasal obstruction or alar
asymmetry in 21% of the cases; some patients required a third procedure, and many of the original
symptoms did not improve. It was notable that the overall degree of patient satisfaction correlated with the
degree of closure of the perforation.
SUMMARY
The inferior turbinate flap did not always prove totally satisfactory for closure of septal perforations.
Complete reconstruction of this difficult problem remains a goal, however, even when some patients

continue to have symptoms.
References
1. Masing H, Gammer C, Jaumann MP. Unsere Konzept zur operatieven Behandlung vom
Septumperforationen. Laryngol Rhinol Otol 1980; 59:50.
2. Gollom J. Perforation of the nasal septum: the reverse flap technique. Arch Otolaryngol 1968;88:84.
3. Tardy ME. Septala perforations. Otolaryngol Clin North Am 1973; 6:711.
4. Fairbanks DNF. Closure of nasal septal perforations. Arch Otolaryngol 1980;106:509.
5. Karlan MS, Ossof R, Christu P. Reconstruction for large septal perforations. Arch Otolaryngol
1982;108:433.
6. Vuyk HD, Versluis RJJ. The inferior turbinate flap for closure of septal perforations. Clin Otolaryngol
1988;13:53.

Chapter 78
Oral Mucosal Flaps for Septal Reconstruction
M. FELDMAN
Z. JABOURIAN
Repair of large septal perforations frustrates even the most experienced surgeon. This problem is exemplified by
the myriad of procedures available for the repair of the perforated septum (1). Small and moderate-sized defects
often can be closed with one of several standard mucosal advancement or rotation flaps; however, larger
perforations (greater than 1.5 cm), once prepared intraoperatively with freshening of the margins, result in
defects that are too formidable for reliable coverage using local flaps. One solution is to bring vascularized tissue
from adjacent sites (2). The oral cavity provides an abundant supply of vascularized mucosa with virtually no
donor-site deformity.
INDICATIONS
Nasal septal perforations may produce symptoms of nasal airway obstruction, dryness, crusting, whistling,
and bleeding. If severe enough, these constitute indications for surgical correction; however, most
perforations are small or very posterior and are usually asymptomatic. These need no intervention.
Nonsurgical management consisting of nasal irrigation, ointments, or silicone buttons should be reserved for
patients with few symptoms, those who refuse surgery, or those with a medical contraindication to surgery
(3).
Each patient should undergo a detailed history with a thorough examination to determine the cause of the
perforation. Before surgery is undertaken, it is critical to control whatever mechanism caused the initial
perforation to prevent recurrence after repair (e.g., nose picking, cocaine abuse, Wegener's vasculitis).
ANATOMY
The oral mucosal flap is a random flap supplied primarily by the superior labial artery. This vessel is often
tortuous, especially in the elderly, and runs in or behind the deeper fibers of the orbicularis oris muscle. It
therefore may lie very superficially beneath the mucosa. A variably defined layer of connective tissue, the
pharyngobasilar fascia, separates the mucosa from the overlying voluntary muscles and provides a surgical
plane for dissection.
FLAP DESIGN AND DIMENSIONS
A medially based flap is outlined intraorally just adjacent to the frenulum in a horizontal fashion along the
gingivolabial sulcus. The dimensions should be tailored according to the amount of mucosa needed for the
repair. This depends on the size and location of the perforation and the distance the flap must travel from its
pedicle (through the gingivolabial sulcus) into the nose. Usually, the flap is 4 to 5 cm long and 1.5 to 2 cm wide. It
is important to note that the flap usually shrinks to two thirds of its original length once it is mobilized. This flap
should contain mucosa, subcutaneous tissue, and fascia, but not muscle.
OPERATIVE TECHNIQUE (4)
A lateral alotomy may be necessary for posterior or larger perforations (Fig. 78.1A). The scar tissue at the edges
of the septal perforation is excised, and the surrounding mucoperichondrium and periosteum are elevated about

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the entire periphery for 5 to 10 mm (Fig. 78.1B).
A flap is outlined along the upper sulcus of the lip with its base adjacent to the superior labial frenulum. The long
axis of the flap runs laterally and upward into the buccal sulcus, avoiding Stenson's duct (Fig. 78.1C). Flap size
should be individualized according to the size and location of the perforation. In general, the flap will measure 1.5
to 2 cm wide and 4 to 5 cm long. Subcutaneous tissue and fascia are included to add bulk and to ensure
adequate blood supply. The donor site can be either closed with chromic sutures or left to heal secondarily.
Using sharp scissors, a tunnel is made through a sublabial incision just cephalad to the flap base into the floor of
the nasal vestibule (Fig. 78.1D). The size of this fistula is critical because flap necrosis will ensue from a tunnel
that is too narrow. The flap is turned over 180 degrees and gently brought through the tunnel into the nasal
cavity with the raw surface away from the perforation (Fig. 78.1E). The edges of the flap are tucked up under the
elevated mucoperichondrium around the perforation. The flap is secured without tension to the septum with a
minimum number of sutures (Fig. 78.1F). The opposite raw surface of the flap is covered with Gelfoam and left to
epithelialize spontaneously. The alotomy incision is closed with subcutaneous and skin sutures, and the nasal
cavity is lightly packed with petrolatum gauze that is removed the following day.
The flap base may be transected in 2 to 3 weeks and the oronasal fistula closed, or the flap may be left attached
at its base and no closure performed.
FIGURE 78.1 A: Lateral alotomy incision made at the alar-facial crease. B: The mucoperichondrium at the edge
of the perforation is elevated about the entire periphery for 5 to 10 mm. C: A medially based flap is outlined and

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sharply elevated. D: Creation of a sublabial-nasal fistula with scissor dissection. E: Flap turned over and brought
into the nasal cavity through the tunnel. F: The edges of the flap are tucked up under the elevated
mucoperichondrium; then sutures are placed.
CLINICAL RESULTS
Although many authors have published their operative technique of choice, few provide objective results.
Three of three successful patients were reported (5), with perforations ranging from 1.5 to 2 cm in diameter;
it has been stated (3), that for large perforations, “the only technique that has been successful in the
author's experience has been the labial mucosal flap.” Other surgeons also have had similar excellent
results using this technique, although well-designed studies are lacking (6). Among the disadvantages of
this procedure are that the oral mucosa does not contain respiratory epithelium and that a second
procedure may be necessary to divide and inset the pedicle.
SUMMARY
Most septal perforations do not need surgical repair. If surgery is indicated, smaller perforations can be
managed with local nasal flaps. The sublabial oral mucosal flap provides an uncomplicated yet reliable
method for repair of large septal perforations with minimal patient morbidity.
References
1. Karlan MS, Ossoff RH, Sisson GA. A compendium of intranasal flaps. Laryngoscope 1982;92:774.
2. Converse JM, ed. Reconstructive plastic surgery, Vol. 2, 2d ed. Philadelphia: Saunders, 1977;1150-1152.
3. Kridel RWH, Appling WD, Wright WK. Septal perforation closure utilizing the external septorhinoplasty
approach. Arch Otolaryngol Head Neck Surg. 1986;112:168.
4. Filiberti AT. Cited in Belmont JR. An approach to large nasoseptal perforations and attendant deformity.
Arch Otolaryngol Head Neck Surg 1985;111:450.
5. Tipton JB. Closure of large septal perforation with a labial buccal flap. Plast Reconstr Surg 1970;46:514.
6. Tardy ME. Personal communication, 1987.

Chapter 79
Local Mucosal Flaps for Closure of Septal Perforations
T. ROMO III
A. D. PATEL
J. M. PEARSON
EDITORIAL COMMENT
This is a clear and useful approach to septal perforations surgery.
Perforations of the nasal septum can lead to symptoms such as whistling, obstruction, crusting, malodorous
discharge, bleeding, and pain. Lasting surgical repair of such perforations can be a challenge, due to limited
intranasal exposure, inelasticity, along with a possibly compromised blood supply to the residual nasal mucosa,
and the desire to preserve mucosal functionality. Different surgical approaches, flaps, and grafts have been
devised, with variable success regarding lasting closure and functionality. Presented here are local mucosal
flaps that are available for use, and the senior author's (TR) graduated approach to nasal septal perforation
repair.
INDICATIONS
Perforations that remain symptomatic, despite adequate medical management, are generally indicated for
surgical closure. Etiologies include inflammatory processes, infections, neoplasms, intranasal substance
abuse, and, most commonly, iatrogenic injury (1). The goal of surgery is to provide a multilayer, tension-
free, physiologic closure while minimizing added morbidity. The appropriate selection of approach and flap
depends on the location, shape, and size of the perforation, relative to the uninvolved nasal mucosa. Prior
to surgical consideration, an extensive workup is paramount, because active disease or substance abuse
generally results in surgical failure (2).
Intranasal mucosal pedicled flaps involve mobilizing and advancing mucoperichondrium or mucoperiosteum
from any location in the nasal vault, including that overlying septum, nasal floor, or lateral wall. These flaps
can be used for perforations of all sizes (1, 3, 4, 5). Moderate-sized, caudal perforations can be closed with
a two-staged transposition of an inferior turbinate flap. Advantages to this technique include abundant
vascularity, wide arc of rotation, combined skeletal and epithelial support, and surgical ease (6, 7). When
adequate healthy nasal mucosa is not available, extranasal mucosal flaps can be used. Examples include
the buccal mucosal flap (8) or the facial artery musculomucosal flap (FAMM) (9), in which the pedicle is
tunneled into the nasal cavity. The disadvantages of these flaps are increased dryness and crusting.
Other approaches that have been described include endoscopic (10), endonasal (5), external rhinoplasty
(11), midface degloving (12, 13), and lateral rhinotomy (14). Greater surgical exposure facilitates more
extensive advancement of healthy nasal mucosa. Generally, more invasive approaches allow greater
exposure at the expense of increased accompanying morbidity.
ANATOMY
Nasal mucosa contains highly dynamic, pseudostratified, ciliated, columnar epithelium that is the basis of the

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mucociliary system. The mucosa lies atop perichondrium in the region of the cartilaginous septum, and atop
periosteum over the bony septum and vault. In general, the periosteum is thicker and stronger than the
perichondrium and so is thought to make a better substrate for repair (4). Between the perichondrium or
periosteum, underlying cartilage or bone is an avascular region, which is the proper plane of dissection for the
flaps. In the septal region, injuring the perichondrium on both sides at opposing locations will compromise the
blood supply to the cartilage, possibly leading to perforation (1). The mucoperichondrial and mucoperiosteal
flaps have no inherent elasticity, but they can be expanded, over time, without apparent loss of function (15).
Blood supply to the nasal mucosa is derived primarily superiorly and posteriorly from the ethmoid and
sphenopalatine
arteries. The anterior supply is provided by the greater palatine artery, after it traverses the incisive canal, and
by nasal branches of the superior labial artery. The vascular supply is interconnected by abundant anastomoses
(1, 3). Nasal mucosal flaps are generally planned to preserve either one or both of these sources of blood
supply. Bipedicled flaps preserve blood supply from both sources. Unipedicled flaps preserve blood supply only
from one source but allow a greater degree of arc rotation.
Oral cavity mucosa consists of nonkeratinized, stratified, squamous epithelium that can secrete mucus but has
no ciliary function. Thus, a buccal mucosal flap, while providing closure, will not preserve regional mucociliary
function. The FAMM flap, which is pedicled on the facial artery, consists of buccal mucosa, submucosa, a small
amount of buccinator muscle, and the deeper plane of the orbicularis oris muscle (16). Extranasal mucosal flaps
are mentioned only briefly here; a more extensive discussion may be found in our original publications.
FLAP DESIGN AND DIMENSIONS
Closure of perforations with intranasal mucosal flaps hinges on the premise that residual, uninvolved, nasal
mucosa, although inelastic, may be mobilized with relaxing incisions that do not compromise major vascular
supply. Fewer incisions are preferred, but not at the expense of adequate mobilization of mucosa.
At the minimum, an anterior-to-posterior directed incision is required in the region of the inferior meatus that
allows the advancement of thicker, more robust mucoperiosteum from the nasal floor and lateral wall in a medial
and superior direction. If mucosal advancement is still not adequate, a caudad-to-cephalad superior incision may
be placed near the junction of the septum and upper lateral cartilages, allowing advancement of a septal flap in a
medial and inferior direction. A transverse incision connecting the former two incisions may be made, to create a
unipedicled flap, thus increasing the arc of rotation. The incision is placed at the level of the posterior nasal
spine and across the anterior nasal sill (12).

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FIGURE 79.1 A: A. 1-cm × 3-cm tissue expander is inserted into a submucoperiosteal pocket on the nasal floor.
A, Nasal septal perforation. B, Long-term expanded nasal-floor mucosa (arrows). C, Peripheral port implanted
onto the maxillary fossa. B: Completion of flap elevation rotation and repair of perforation. A, Middle turbinate. B,
Posterior naris. C, Inferior turbinate infractured. D, Raw surface area left by flap rotation. E, Full-thickness skin
graft on floor of nose. F, Rotated flap. G, Anterior septal angle.
The size and location of the perforation dictate the degree of surgical exposure required. The amount of
available mucosa for approximating edges of perforation varies inversely with the size of perforation (3).
Therefore, larger perforations require greater exposure, in order to mobilize a sufficiently large flap. Posterior
perforations are difficult to access with an endonasal approach. Thus, although endonasal approaches, with or
without alotomy, are adequate for small, anterior perforations, large and posterior perforations generally require
the exposure provided by external rhinoplasty and midface degloving. The senior author uses an extended
external rhinoplasty approach, with or without a midface degloving, employing the standard transcolumellar, full
transfixion, bilateral intercartilaginous, and gingivobuccal incisions (13).
If the amount of uninvolved nasal mucosa is not adequate to allow tension-free perforation closure, tissue
expansion is a means of flap lengthening that preserves nasal histology and, therefore, physiology (Fig. 79.1). A
gain of 5 cm is expected from a 1-cm × 3-cm tissue expander (PMT Accuspan Corp.,
Chanhassen, MN), described in the senior author's previous study. Expansion is a multistage process, requiring
a period of at least 6 weeks (15).
More successful outcomes are associated with a multilayered closure involving grafts of connective tissue
interposed between the left and right repaired mucoperichondrium. The interposition grafts help prevent
incisional breakdown and reperforation, by serving as templates for overlying mucosal-tissue migration and
vascularization and by providing a barrier between the healing flaps. Possible grafting materials include
uninvolved septal cartilage, ethmoid bone, auricular cartilage, temporalis fascia, mastoid perichondrium, and
human acellular dermal graft (Alloderm, LifeCell Corp., The Woodlands, TX). The advantage of Alloderm is the
elimination of donor-site morbidity (2).

Inferior turbinate flaps involve the inferior half of the turbinate, pedicled anteriorly, which may include part of the
bone. The flap is rotated anteriorly and adjusted to fill the perforation. The contralateral side may be left to heal
by secondary intention, or bilateral turbinate flaps may be used. The pedicle is taken down after 3 weeks (7).
OPERATIVE TECHNIQUE
Preoperative intensive nasal care and hygiene are recommended. The latter may include antibiotic use, frequent
saline irrigation, and lubrication with emollients. Once proper hygiene is established, chronic inflammation may
be stabilized with a topical nasal steroid spray.
The senior author has developed a graduated approach to septal perforation repair with
mucoperichondrial/periosteal advancement flaps (12). For anterior perforations less than 0.5 cm, an endonasal
approach is used (Fig. 79.2), to develop opposing bipedicled flaps. For perforations 0.5 to 2 cm, an external
rhinoplasty approach is used (Fig. 79.3), to develop bilateral, posteriorly based, unipedicled flaps. For
perforations larger than 2 cm, the closure is undertaken in two stages. The first involves placing an intranasal
tissue expander for 6 weeks, and the second involves an external rhinoplasty approach, with midface degloving,
to develop bilateral, posteriorly based, unipedicled flaps.
FIGURE 79.2 Completed repair with nasal floor mucosal flaps. Closure of perforation and nasal packing. A,
Alloderm dermograft. B, Rotated nasal-floor mucosal flaps. C, Thin silicone sheeting secured to nasal mucosal
flaps. D, Surgical sponge (Telfa) dressing. E, Surgical sponge (Merocel). F, Skin graft covering donor site.

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FIGURE 79.3 Extended external rhinoplasty approach. Exposure of nasal septal perforation using the extended
external rhinoplasty approach. A, Columella flap retracted. B, Cartilaginous perforation. C, Mucosal perforation.
D, Mucosa elevated and reflected laterally.
The nose is prepared with sponges or pledgets soaked with a topical decongestant, such as phenylephrine or
oxymetazoline. The nasal and paranasal soft tissues are injected with standard lidocaine (Xylocaine)/epinephrine
preparations.
For the external rhinoplasty approach, a transcolumellar incision is first made at the base of the columella and
dissected inferiorly under the feet of the medial crura and posteriorly to the caudal septum. Bilateral
intercartilaginous incisions are made and connected to a full transfixion incision that spans over the septal angle
and through the membranous septum. The columellar and medial crural flaps are elevated superiorly, thus
exposing the caudal septum.
For midface degloving, a complete gingivobuccal sulcus incision is made, with cautery, between the right and left
upper first molars. The osseocartilaginous nose is then degloved over the upper lateral cartilage and nasal
bones. The dissection is carried posteriorly and laterally over the nasal bones down onto the maxilla. The
intranasal incisions are then connected sharply to the gingivobuccal incision, between the pyriform apertures
across the anterior nasal spine. The face of the maxilla is then stripped with a periosteal elevator, identifying the
edges of the pyriform aperture and the infraorbital nerves. This dissection is connected with the nasal degloving
dissection. The tip structures and upper lip are retracted superiorly, and the last remaining bridge of tissue lateral
to the pyriform aperture and upper lateral cartilages is divided with cutting cautery. The midface is now degloved,
isolating the nasal fossae at the level of the pyriform aperture, nasal valve, and
anterior septal angle. The nasal tip, upper lip, and midfacial soft tissues are retracted superiorly and secured
with half-inch Penrose drains.
Once the appropriate exposure is established, the rim of the perforation is debrided. The mucoperichondrial flaps
are elevated bilaterally along the remainder of the septum, which, if deviated, is removed or straightened. The
flap is elevated superiorly to the junction of the septum and upper lateral cartilage, anteriorly to the anterior
septal angle, and inferiorly to the maxillary crest. A transverse mucosal incision may be made from the posterior
nasal spine across the anterior nasal sill, up onto the lateral pyriform aperture, to the level of the insertion of the
inferior turbinate.
The mucoperiosteum of the nasal floor and inferior meatus is elevated laterally to the insertion of the inferior

turbinate, medially to the maxillary crest (where the decussating fibers are carefully incised), and posteriorly to
the junction of the hard and soft palates. The inferior turbinate is fractured medially, allowing a full-thickness
incision to be made through the inferior meatal mucosa just below the insertion of the turbinate. A back cut is
made at the posterior portion of this incision toward the nasal floor, allowing full medialization of this posteriorly
based mucoperiosteal flap.
Now, the intranasal mucosa is mobile from the upper lateral cartilages down to the maxillary crest, across the
nasal floor, and up to the inferior turbinate. The flap is rotated medially across the floor and up the septum, until
the inferior and superior edges of the perforation meet. These two mucosal edges are closed with interrupted 5-0
Vicryl suture from posterior to anterior. If excess tension remains, a relaxing incision is made near the septum-
upper lateral cartilage junction, allowing inferior displacement of the superior flap.
The senior author's interposition graft of choice is AlloDerm. This is secured between the two nasal mucosal
flaps to the septal cartilage with 5-0 Vicryl suture, superior to the perforation, and allowed to drape over and
totally cover the perforation on one side of the septal cartilage. The repaired mucoperichondrial flaps are placed
into position, and the denuded nasal floor is covered with a full-thickness postauricular skin graft to prevent
vestibular stenosis. This graft is secured in place to the nasal sill and medialized mucosal flap with interrupted 5-
0 Vicryl suture.
For external rhinoplasty, the intercartilaginous and transfixion incisions are then closed with 4-0 chromic suture,
and the columellar incision is closed with 6-0 Prolene suture. When necessary, the medial crural feet are
resuspended from the caudal septum with a 4-0 chromic mattress suture. For midface degloving, the intraoral
incision is closed with a running 3-0 chromic suture.
Bilateral silicone sheeting is fixated external to the mucosal flaps with 4-0 nylon suture. Finally, a Telfa pad,
wrapped over a Merocel sponge, is placed as packing and intranasal support. The packing and external splints
are removed on the seventh postoperative day, while the silicone splint is maintained in position until the fourth
to sixth postoperative week.
For those defects that require tissue expansion, the previously mentioned procedure is preceded by placement
of tissue expanders under a mucoperiosteal pocket in the bilateral nasal floors. The mucosa of the anterior nasal
sill is incised and carried laterally up onto the pyriform aperture. The nasal floor and inferior meatal
mucoperiosteum are elevated, and a 1-cm × 3-cm tissue expander is inset into the nasal floor pocket. Elevation
of medial maxillary soft tissue is accomplished through a mucosal incision at the inferior pyriform aperture. The
peripheral port of the expander is placed onto the maxilla and connected to the expander. Care is taken to
prevent bending or kinking of the tubing. Approximately 0.2 mL of sterile saline dyed with methylene blue is
instilled into the peripheral port, to slightly inflate the expander. The mucosal incision is closed with interrupted 4-
0 chromic suture; nasal packing is not used.
Two weeks postoperatively, small aliquots (0.5 to 1.0 mL) of sterile saline are injected into the peripheral port
through an intraoral approach. A transcutaneous injection into the peripheral port may be performed, but this
usually requires a preinjection, infraorbital nerve block with local anesthesia. Expansion is performed on a
weekly basis and typically requires 6 to 8 weeks to reach a total expander volume of 4 to 7 mL. Once the desired
amount of mucosal expansion is achieved, the repair is performed, as previously described, after a midface
degloving approach and removal of the tissue expanders.
Caudal perforations of a moderate size are amenable to an inferior turbinate flap (7). After the nose is prepared,
a full-thickness incision is started from the posteromedial margin of the turbinate and extended anteriorly. The
incision is ended prior to the turbinate's insertion into the lateral wall, thus preserving the anterior blood supply.
In cross-section, the U-shaped flap contains mucosa and submucosa from both the medial and lateral surfaces of
the turbinate and possibly turbinate bone within. The flap is rotated medially and anteriorly on itself. The distal

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segment is opened and fit to fill the perforation, such that the submucosal surface faces medially and the
mucosal surface faces the nasal airway. It is sutured with 4-0 plain gut suture to the septal rim. The donor site is
typically left to heal by secondary intention. The contralateral side of the perforation may also be left to heal by
secondary intention, or bilateral inferior turbinate flaps may be created. The pedicle is taken down in 3 weeks.
CLINICAL RESULTS
Results over the past 30 years by the author and others (6, 9, 12, 17) have shown good to excellent closure
of defects utilizing a variety of approaches, from the smallest to the largest and more complex approaches.
Reports vary from 75% to 100% of closure over all techniques.
Causes for reperforation include perioperative infection, closure under tension, lack of intervening
connective tissue, and presence of persistent inflammatory or neoplastic disease (2). Complications specific
to the inferior turbinate flap include the development of synechiae and nasal stenosis (7). Complications
associated with tissue expansion include infection, expander exposure, implant failure, ischemia of
expanded mucosa, seroma formation, and widening of donor scars (15).
SUMMARY
Advancement of mucoperichondrial/periosteal flaps, with placement of connective tissue interpositional
grafts, can lead to a successful and functional repair of septal perforations. The appropriate approach for a
particular perforation allows adequate mucosa to be mobilized for a tension-free closure. Tissue expansion
facilitates lengthening of nasal mucosa, thus avoiding the use of extranasal tissues. Alternative methods,
such as inferior turbinate flaps or oral mucosal flaps, may be useful in particular situations.
References
1. Fairbanks DN. Closure of nasal septal perforations. Arch Otolaryngol 1980;106:509.
2. Kridel RW. Septal perforation repair. Otolaryngol Clin North Am 1999;32:695.
3. Gollom J. Perforation of the nasal septum. The reverse flap technique. Arch Otolaryngol 1968;88:518.
4. Karlan MS, Ossoff R, Christu P. Reconstruction for large septal perforations. Arch Otolaryngol
1982;108:433.
5. Belmont JR. An approach to large nasoseptal perforations and attendant deformity. Arch Otolaryngol
1985;111:450.
6. Vuyk HD, Versluis RJ. The inferior turbinate flap for closure of septal perforations. Clin Otolaryngol Allied
Sci 1988;13:53.
7. Friedman M, Ibrahim H, Ramakrishnan V. Inferior turbinate flap for repair of nasal septal perforation.
Laryngoscope 2003;113:1425.

8. Tipton JB. Closure of large septal perforations with a labial-buccal flap. Plast Reconstr Surg 1970;46:514.
9. Heller JB, Gabbay JS, Trussler A, et al. Repair of large nasal septal perforations using facial artery
musculomucosal (FAMM) flap. Ann Plast Surg 2005;55:456.
10. Hier MP, Yoskovitch A, Panje WR. Endoscopic repair of a nasal septal perforation. J Otolaryngol 31:323,
2002.
11. Kridel RW, Appling WD, Wright WK. Septal perforation closure utilizing the external septorhinoplasty
approach. Arch Otolaryngol Head Neck Surg 1986;112:168.
12. Romo T 3rd, Foster CA, Korovin GS, Sachs ME. Repair of nasal septal perforation utilizing the midface
degloving technique. Arch Otolaryngol Head Neck Surg 1988;114:739.
13. Romo T 3rd Sclafani AP, Falk AN, Toffel PH. A graduated approach to the repair of nasal septal
perforations. Plast Reconst Surg 1999;103:66.
14. Karlan MS, Ossoff RH, Sisson GA. A compendium of intranasal flaps. Laryngoscope 1982;92(7 Pt 1):774.
15. Romo T 3rd, Jablonski RD, Shapiro AL, McCormick SA. Long-term nasal mucosal tissue expansion use
in repair of large nasoseptal perforations. Arch Otolaryngol Head Neck Surg 1995;121:327.
16. Pribaz J, Stephens W, Crespo L, Gifford G. A new intraoral flap: facial artery musculomucosal (FAMM)
flap. Plast Reconstr Surg 1992;90:421.
17. Pedroza F, Patrocinio LG, Arevalo O. A review of 25-year experience of nasal septal perforation repair.
Arch Facial Plast Surg 2007;9:12.

Chapter 80
Eave Skin Flap for Helical Reconstruction
M. L. LEWIN
EDITORIAL COMMENT
This is an important principle not only in ear reconstruction, but at other sites in the body where one flap is
required to fold into another flap, such as in alar-base reconstruction.
The helix is the most prominent part of the external ear, visible when viewing the face from the front and even
more conspicuous in profile. The most frequent deformity of the helix occurs in facial burns. Because of its
prominence and its thin skin and cartilage, the helix is often destroyed, leaving the auricle with a flat, scarred,
jagged rim (Figs. 80.1A and 80.2A). Other helical deformities are due to lacerations, excision of tumors, or
harvesting of large composite grafts (1).
INDICATIONS
If the helical defect is small, it is best repaired by a chondrocutaneous flap, but if the defect is larger than
2.5 cm, this procedure will reduce the size of the auricle. Several procedures are recommended for
reconstruction of the helix. Some may require multiple stages, may leave conspicuous scars, or are
applicable only to small helical losses.
The eave skin flap was devised primarily for isolated defects of the helix (2). It can be used to reconstruct
the entire helix or a portion of it (3) in a two-stage procedure that can be performed with the patient under
local anesthesia without hospitalization. It uses the postauricular and mastoid skin, which is a good match
for the skin of the ear. The flap donor-site scar or skin graft is concealed behind the ear.
In assembling the cartilaginous framework in total ear reconstruction provision is made for the helix. A
vertical strip of cartilage extends above the horizontal plane of the scapha; however, the skin flap that
covers the cartilaginous framework frequently effaces the prehelical sulcus so that the helical outline is lost.
An eave flap can restore the sharp delineation of the helix. The eave flap is not advised when the ear
framework is of alloplastic material.
FLAP DESIGN AND DIMENSIONS
The procedure is based on the observation that a skin flap that is dissected free and held at both ends will curl
until it spontaneously tubes itself. This curling is caused by the contracture of the denuded undersurface of the
flap. If half the width of the flap is inserted into the tissue and the other half is unattached, the latter will curl until
its undersurface becomes completely epithelialized.

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FIGURE 80.1 Diagram of procedure (see text). A: Preoperative appearance. B: Helical defect denuded by
excision of marginal scar. The mastoid flap is incised. C: Formation of postauricular skin tunnel. D: Mastoid flap
overlapping helical defect like an eave. E: Postoperative appearance. (From Lewin, ref. 2, with permission.)
FIGURE 80.2 A: Loss of helix due to burn. B: Eave flap after first stage. Overlap is tapered so that it flattens at
the inferior pole. C: Final appearance. Soft curvature and delicate outline of the helix. Smooth junction at both
ends. (From Lewin, ref. 2, with permission.)
OPERATIVE TECHNIQUE
The defective margin of the auricle is denuded by excision of the marginal scar (Fig. 80.1B). If a portion of the
helix remains on either end of the defect, it is incised for a few millimeters. Later, the tips of the flap will be
inserted into these cuts to obtain a tongue-in-groove junction.
By pressing the auricle against the mastoid, the length of the flap is outlined, and an incision is made a few
millimeters posteriorly. At both ends of this incision, perpendicular divergent incisions are made, thus widening
the flap as it extends posteriorly (Fig. 80.1B). The upper incision is about 2.5 cm long, and the lower is
considerably shorter. The latter can be dispensed with if the lower pole of the flap extends below the middle of

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the auricle where the helix is flat. These incisions outline the mastoid skin flap.
The anterior margin of the postauricular incision (Fig. 80.1B) is approximated to the posterior edge of the
denuded helical defect (Fig. 80.1B), which forms a skin-lined tunnel and also bends the auricle backward,
holding it in close approximation to the mastoid (Fig. 80.1C). The suturing is done with fine catgut or Dexon,
knotted on the skin surface inside the tunnel.
The incised mastoid skin flap is undermined for a distance of about 3 cm. Its anterior free margin (Fig. 80.1B,
CC) then can easily overlap the margin of the auricle (Fig. 80.1D). The overlapping must be free of any tension,
or the flap will retract and flatten during the healing period. The upper and lower corners of the flap are sutured
into the open incisions along the margin of the defect.
The anterior margin of the mastoid skin flap—the eave flap—overlaps the scaphal surface for a distance of 3 to 6
mm (Fig. 80.1D, C-CB). More overlap is allowed in the upper portion to obtain the effect of tapering off. Three or
four double-armed nylon sutures are inserted into the anterior lip of the helical defect (Fig. 80.1D, B-CB) and
passed through the flap. They then are tied over bolsters about 2.5 cm posterior to the free margin of the flap
(Fig. 80.1E). The sutures control the amount of overlapping.
Packing is inserted into the postauricular skin tunnel and underneath the overlap. Within 3 weeks, the
undersurface of the overlap is epithelialized, and there is a noticeable curling of the anterior border of the flap
(Fig. 80.2B).
The second stage is usually carried out 3 weeks later. The necessary width of the flap is estimated, and the flap
is cut free from the mastoid. The skin-lined tunnel is incised, allowing the pinna to return to its normal position.
The posterior border of the flap then is trimmed as needed and sutured to the remaining skin on the medial
surface of the auricle (Fig. 80.1B, AA). With the flap widening at its base, the divergent suture lines facilitate a
smooth junction with the edges of the defect. The mastoid defect can be closed by advancing scalp skin,
although a skin graft is usually used.
This procedure can be modified according to the requirements of each patient. If the helical defect is wide and a
longer flap is needed, the mastoid flap can be made longer by dispensing with the skin tunnel and using all the
skin on the medial surface of the auricle so that the entire auricle adheres to the skull.
CLINICAL RESULTS
The curling effect of the thin mastoid or auricular skin gives an excellent simulation of the normal helix (Fig.
80.2C). If the helical flap includes scalp skin or a skin graft, however, the result is usually less satisfactory
because the reconstructed helix is thicker, bulkier, and curls irregularly.
SUMMARY
The eave skin flap can be used to recreate the helical rim by taking advantage of the natural tendency of
the free edge of a flap to curl.
References
1. Lewin ML. Reconstruction of the helix. Arch Otolaryngol 1948;47:802.

2. Lewin ML. Formation of the helix with a postauricular flap. Plast Reconstr Surg 1950;5:432.
3. Argamaso RV, Lewin ML. Repair of partial ear loss with local composite flap. Plast Reconstr Surg
1968;42:437.

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Chapter 81
Retroauricular Tubed Skin Flap to The Helical Rim
D. N. STEFFANOFF
The retroauricular tubed skin flap has proved an excellent choice for reconstruction of the auricle because of its
color and texture match, rich blood supply, and proximity to the deformity (see also Chapter 86).
INDICATIONS
Problems of auricular reconstruction involve restoring cartilaginous support, supplying soft-tissue coverage
of similar color and texture, and positioning the auricle at the proper angle to the side of the head (1, 2, 3, 4,
5). The retroauricular tubed skin flap allows the surgeon to meet all these requirements for a satisfactory
cosmetic reconstruction of a partially mutilated auricle (6).
ANATOMY
The retroauricular skin and subcutaneous tissue are supplied by the postauricular artery, which is a branch of
the external carotid artery. The anterior and lateral auricular skin is supplied by branches of the temporal artery.
OPERATIVE TECHNIQUE
The first patient benefiting from this surgical approach presented with a loss of 60% of the helical rim and 40% of
the chonchal-anthelical skin and cartilaginous support as a result of a human bite (Fig. 81.1). The following steps
illustrate the initial reconstruction:
1. Forming the retroauricular tubed skin flap, which in this patient measured 68 mm long and 16 mm wide (Fig.
81.1B and C). The postauricular artery is included in the flap.
2. Delaying the incision through half the circumference of the cephalic end of the flap.
FIGURE 81.1 A: Human bite deformity with 60% loss of helical rim and 40% loss of the chonchal-anthelical
skin and cartilaginous support. B: Incisions for the bipedicle retroauricular flap. (Continued)

FIGURE 81.1 Continued. C: Tubed skin flap partly retracted, revealing denuded donor site, which was closed
by direct suture of wound edges. D: Retroauricular tubed skin flap sutured to the cephalic portion of the helical
rim. E: Postauricular flap of mastoid skin and the underlying cartilaginous graft for reconstruction of the
partially deficient concha and anthelix. F: The postauricular flap with underlying cartilage graft and split-
thickness skin graft placed on the back side of the cartilage and the flap donor site. G: Closeup of auricular
reconstruction.
3. Transferring the cephalic end of the tubed flap to the cephalic portion of the helical rim (Fig. 81.1D).
4. Delaying the incision through half the circumference of the caudal end of the tubed flap and delaying the
incision and undermining of the mastoid skin, where a cartilage graft will be placed, partially to reconstruct the
concha and anthelix.
5. Transferring the caudal end of the tubed skin flap to the caudal end of the deformity, near the earlobe.
6. Burying the carved cadaver cartilaginous support to simulate the lost portion of the concha and anthelix (Fig.
81.1E). This cartilage was stored in absolute ethyl alcohol, but it was placed in saline for 30 minutes prior to
its use.
7. Incising behind the cartilage graft to permit the external ear to be elevated to the proper angle with the side of
the head. Soft tissue is maintained with the cartilage to accept a 0.016-in. split-thickness skin graft from the
medial upper arm (Fig. 81.1F).
8. The tubed flap is incised longitudinally along its original suture line and sutured to the incised margin of the
postauricular flap using a plaster cast model of the opposite ear for comparison.
The completed reconstruction is shown in Figure 81.1G.

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SUMMARY
The retroauricular tubed skin flap can be used to reconstruct large defects of the helical rim of the external
ear.
References
1. Ford JF. A method of plastic reconstruction of the auricle: preliminary report. Plast Reconstr Surg
1946;1:332.
2. Fomon S. The surgery of injury and plastic repair. Baltimore: Williams & Wilkins, 1939.
3. Maliniac JW. Reconstruction for partial loss of ear. Plast Reconstr Surg 1946;1:124.
4. Barsky AJ. Plastic surgery. Philadelphia: W. B. Saunders, 1938.
5. O'Connor GB. Establishment of cartilage depots for military and civil use (editorial). Am J Surg
1942;58:313.
6. Steffanoff, DN. Auriculomastoid tube pedicle for otoplasty. Plast Reconstr Surg 1948;3:352.

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Chapter 82
Preauricular Translobular Flap for Reconstruction of Auricular
Defects
RANDALL S. FEINGOLD
EDITORIAL COMMENT
Excellent technique for small flaps of the helix, providing full-thickness coverage, minimal scarring, and
reasonably good color match. Exposed cartilage should be removed to avoid suppuration.
INDICATIONS
A preauricular skin flap tunneled through the ear lobule is a versatile method for coverage of exposed ear
cartilage and reconstruction of full-thickness defects of the middle third of the helical rim. Many techniques
for reconstructing partial- and full-thickness auricular defects acquired through tumor resection, infection,
trauma, or burn injury have been described including skin grafts, chondrocutaneous flaps (1), two-stage
retroauricular flaps with or without cartilage grafts (2, 3), composite chondrocutaneous graft (4, 5), or
pedicled tube skin flaps (6). This flap allows for single-stage coverage of exposed or infected cartilage that
would not support a skin graft or chondrocutaneous graft, and while reconstruction of midhelical defects of
the ear is well accomplished through a chondrocutaneous flap technique, disadvantages include shortening
of ear height and the potential for hematoma following dissociation of the helical flap from the
conchoscaphal framework. The preauricular translobular flap has been employed in patients with midhelical
rim defects due to radical resection of basal cell carcinoma and malignant melanoma with defects
measuring as large as 4 cm long and 1 cm wide.
ANATOMY
The auricle and, in particular, the helical rim consist of a curved cartilage framework wrapped with thin skin.
While some of the well-described techniques restore the anatomy with both skin and cartilage, the preauricular
flap does not itself supply cartilage. Nevertheless, it will suffice to resurface partial-thickness defects with
exposed cartilage, and it will provide an aesthetically excellent reconstruction of the full-thickness midhelical
defect. Blood supply to the flap derives from the superficial temporal artery.
FLAP DESIGN AND DIMENSIONS
The flap is drawn in the preauricular skin, extending from the sideburn to the ear lobule, measuring 6 cm in
length and 1.5 cm in width based in front of the ear lobule (Fig. 82.1). The design for the working part of the flap
and its soon to
be de-epithelialized pedicle is demonstrated in the patient in Figure 82.1, who is undergoing radical resection of
melanoma and sentinel lymph node biopsy.

FIGURE 82.1 Flap design.
FIGURE 82.2 Flap tunneled through the lobule to define the working skin paddle.
OPERATIVE TECHNIQUE
The flap is elevated at the level of the parotid fascia to capture blood supply from the superficial temporal artery.
A tunnel is then created through the lobule at its point of attachment so the flap can be passed through to the
defect. This allows delineating which portion of the flap will be used as the skin island and which portion will
become the proximal de-epithelialized pedicle (Fig. 82.2). After marking these territories, the flap is withdrawn
from the lobule so it can be de-epithelialized (Fig. 82.3). The flap is then brought back through the lobule for
insetting into the defect and the donor site is closed with cheek skin advancement into the preauricular crease
(Fig. 82.4).
CLINICAL RESULTS
In our experience, all flaps have survived entirely with excellent cosmesis of the helical rim contour and the
preauricular donor site. No deformities of the lobule were noted. The patients who underwent tumor
resection and immediate flap reconstruction had uncomplicated wound healing. A patient with painful
ulceration and exposed cartilage due to Acinetobacter chondritis (Fig. 82.5) underwent debridement of
infected cartilage (Fig. 82.6), immediate flap reconstruction (Fig. 82.7), and oral antibiotic therapy and
enjoyed rapid and sustained wound healing with resolution of chronic pain and erythema (Figs. 82.8 and
82.9). In this particular case, dissociation of the ear into chondrocutaneous flaps was undesirable due to the
infection, and skin grafting was similarly contraindicated. Postoperative edema of the ear in all cases was
noted to be minimal in the first few weeks.

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FIGURE 82.3 Withdrawn flap is de-epithelialized.
FIGURE 82.4 Flap inset and donor site are closed.
FIGURE 82.5 Infected ulceration with exposed cartilage.

FIGURE 82.6 Debridement of infected cartilage and flap design.
FIGURE 82.7 Flap inset with donor site closed.