Local Flaps in Facial Reconstruction

396
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 17-8  ■  Proper design of rhombic flaps in periorbital region.
A
B
FIGURE 17-9  ■  Transposition flap used to repair anterior lamellar defect of lower eyelid. Flap can be transferred as cutaneous or
musculocutaneous flap.
A
B
FIGURE 17-10  ■  Unipedicle advancement flap used to repair skin and muscle defect.
A
B

17  RECONSTRUCTION OF THE EYELIDS
397
FIGURE 17-11  ■  Musculocutaneous advancement flap used to repair medial upper eyelid defect. When it is combined with lower
eyelid and cheek advancement flaps, large medial canthal skin defects can be successfully repaired.
FIGURE 17-12  ■  Eyelid defect repaired with anterior lamella
flaps. A, Lower eyelid and medial canthal defect. B, Defect
closed with medial canthopexy to reinforce medial canthal
tendon, rhombic flap from nose, and advancement flap from
melolabial fold. C, Postoperative view at 1 year. Note mainte­
nance of lower eyelid height.
A
B
C

398
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
incorporated into the skin closure to avoid corneal irrita­
tion (Figs. 17-13 and 17-14). Alternatively, 6-0 silk inter­
rupted sutures can be placed at the gray line and the lash
line to create wound eversion.
Repair of the orbicularis oculi is next performed with
buried interrupted 6-0 polyglactin sutures. More hori­
zontal wound tension is often appreciated with closure of
this layer than with any other. Meticulous approximation
here will result in a tension-free skin closure and the best
possible scar.
Final closure of the skin will typically result in a verti­
cal scar. Suture approximation can be accomplished with
any 6-0 material; pleasing results have been obtained
with nylon, polypropylene, silk, and even polyglactin.
initial suture placement, additional interrupted sutures
are placed to completely approximate the tarsus. The
eyelid retractors (levator aponeurosis or capsulopalpebral
fascia) are repaired similarly, avoiding full-thickness
suture passage that will later abrade the cornea.
Once perfect vertical alignment has been established,
anteroposterior alignment of lid margin structures must
also be restored. Eversion of the eyelid margin wound is
necessary to avoid notching and is accomplished during
this phase of tarsal repair. The most consistently success­
ful technique is to place a vertical mattress suture at the
gray line, tied to create significant eversion. A 4-0 silk
suture on a G-1 or G-3 needle is well suited to this
application, and once tied, the ends are left long and
FIGURE 17-13  ■  A, Full-thickness defect of eyelid. Lateral cantholysis may be performed to facilitate primary wound closure. B, To
avoid corneal irritation, sutures are passed through anterior two-thirds of tarsal plate (1, 2) and capsulopalpebral fascia/levator
(3). Precise approximation of eyelid margin is achieved with a vertical mattress suture (4). C, The mattress suture ends are incor­
porated into the skin closure to avoid corneal irritation. D, Detail view.
B
A
C
D
1
2
3
4
FIGURE 17-14  ■  Intraoperative photographs of full-thickness defect repair. A, Tarsus repaired with 6-0 polyglactin, and eyelid margin
alignment established with first pass of 4-0 silk. B, Second pass of silk vertical mattress suture facilitated by upward tension on free
ends of first pass. C, Mattress suture tied with tension to cause mild eversion.
A
B
C

17  RECONSTRUCTION OF THE EYELIDS
399
close full-thickness defects of the eyelid that encompass
33% to 75% of the horizontal length of the lower eyelid
and 30% to 66% of the upper eyelid. Initially described
by Richard Tenzel in 1978,13 this flap is conceptually
similar to the classic Mustarde cheek rotation flap14 for
eyelid reconstruction but provides better dynamic recon­
struction of the eyelid lamellae with considerably less
tissue rearrangement. There are several variations in the
technique that can be chosen on the basis of individual
patient characteristics. In each case, the anterior lamella
(skin and orbicularis muscle) and posterior lamella (tarsus
and conjunctiva) of the eyelid are addressed in a single-
stage operation (Fig. 17-16).
Indications for use of the Tenzel flap include full-
thickness central or lateral eyelid defects of 30% to 75%
of the length of the original lower eyelid margin and 30%
to 66% of the upper eyelid margin. Such defects are com­
monly a result of trauma, micrographic surgery for skin
cancer, or congenital eyelid coloboma. The Tenzel flap is
most useful when there is adequate lateral canthal skin
laxity and availability of at least a small segment of full-
thickness eyelid on both sides of the defect. This flap can
be used when there is no tarsus on the lateral side of the
defect, but optimal results will require a periosteal flap or
Arrowhead flap closure of the skin defect may result in a
shorter scar12 and is used when possible. Postoperative
dressing consists only of erythromycin ophthalmic oint­
ment, preferred for its low toxicity and allergenicity.
Ointments or eye drops that contain steroids should be
avoided. Removal of the vertical mattress silk suture at
the lid margin is delayed for 10 to 14 postoperative days.
Skin sutures may be removed earlier if desired. Examples
of primary eyelid repair with the suture techniques dis­
cussed are seen in Figure 17-15.
Complications from primary full-thickness eyelid
repair include notching of the eyelid margin, trichiasis,
eyelid retraction, blepharoptosis, pyogenic granuloma,
and corneal exposure. Risk of corneal ulceration and
visual loss exists if sutures touch the cornea; hence, great
care must be taken during the posterior lamellar closure
and placement of eyelid margin eversion sutures.
SEMICIRCULAR FLAP RECONSTRUCTION OF
LARGER FULL-THICKNESS DEFECTS
The Tenzel semicircular advancement flap is a useful
technique in eyelid reconstruction and is well suited to
FIGURE 17-15  ■  Primary closure of full-thickness eyelid margin defects after resection of skin cancer. A, B, Before and after resection
of melanoma. C, D, Before and after resection of basal cell carcinoma.
A
B
C
D

400
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
sharp tungsten needle may also be used, with the genera­
tor set on minimum blend. A lateral canthotomy incision
is made beneath the musculocutaneous flap, and the infe­
rior ramus of the lateral canthal tendon is cut to com­
pletely mobilize the lateral lower eyelid segment. The
musculocutaneous flap is thoroughly undermined and
advanced medially so that the lateral lid tissue is advanced
to the medial edge of the defect. In most cases, there is
adequate skin laxity in the lateral canthal/temporal region
for development of a Tenzel flap, but increased tissue
advancement can occasionally be gained with rapid intra­
operative tissue expansion with a Foley catheter placed
beneath the skin of the temple. Two 5-minute cycles of
skin expansion are used before flap advancement.15
Careful approximation of the two tarsal edges is the
most important part of the reconstruction. With use of
6-0 polyglactin on a spatula needle (e.g., S-14), the tarsal
edges are united with an interrupted suture that precisely
approximates the lid margin as described before. A second
and third interrupted suture is placed to further approxi­
mate the tarsus.
Lid margin sutures are placed in the gray line to per­
fectly align the lamellae of the eyelid at the wound edges.
When enough full-thickness eyelid tissue is available on
either side of the wound, the preferred technique is to
place a vertical mattress 4-0 silk suture at the gray line
for improved eversion of the superior eyelid margin. If
instead one edge of the wound consists of a very small
portion of full-thickness eyelid, simple interrupted 6-0
silk sutures are placed at the gray line and the lash line.
In either case, to avoid corneal irritation, the ends of the
a posterior lamellar graft such as hard palate mucosa or
auricular cartilage (see later). In cases with a history of
previous irradiation or burn, the Tenzel advancement flap
is preferred to grafting as the flap provides its own blood
supply. In general, the final postoperative appearance of
the flap is superior to reconstruction with a skin graft or
the larger Mustarde flap.
After anesthetic infiltration, initial intraoperative anal­
ysis begins with estimation of the actual size of the defect
by grasping the borders of the wound with fine-toothed
forceps (e.g., fine Adson or 0.5-mm Castroviejo forceps)
and pulling them together. If the borders are within 1- to
2-mm of one another, primary closure with lateral can­
tholysis may be all that is necessary. If the defect is 30%
to 75% of the horizontal length of the lower eyelid (typi­
cally 29- to 33-mm overall) or 30% to 66% of the upper
eyelid, the Tenzel semicircular advancement flap will
probably be an excellent choice for reconstruction. For
larger defects, the Hughes and Cutler-Beard flaps may be
more effective.
Reconstruction of the lower eyelid by the Tenzel flap
is as follows. Beginning exactly at the lateral canthus, a
semicircular superior arching line is drawn with a diam­
eter of approximately 20-mm extending toward the level
of the lateral eyebrow line (Figs. 17-16 and 17-17). For
upper eyelid reconstruction, the mirror image is used.
Next, the tarsal edges are freshened as necessary so that
they are perfectly perpendicular to the lid margin, sacri­
ficing as little tissue as possible. A Bard-Parker No. 15
blade is used for the initial incision and dissection of the
musculocutaneous flap. Limited electrodissection with a
FIGURE 17-16  ■  A, Tenzel flap incised. B, Flap consisting of skin and orbicularis muscle is elevated and widely undermined. C, Lateral
canthotomy and cantholysis (broken line) are performed. Eyelid defect is then repaired as in primary wound closure.
A
B
C

17  RECONSTRUCTION OF THE EYELIDS
401
FIGURE 17-17  ■  Tenzel semicircular flaps. A, Upper eyelid defect. B, Defect shown in A closed with Tenzel flap. C, Full-thickness lower
eyelid defect. Tenzel flap designed for repair. D, Right lower eyelid squamous cell carcinoma. E, Same patient as shown in D 1 week
after repair with Tenzel flap. F, G, Same patient as shown in D. Preoperative and 1-year postoperative views.
A
B
C
D
G
E
F
sutures are left long after tying so that later they can be
incorporated into a knot inferiorly on the skin.
To prevent lateral sagging of the eyelid, lateral canthal
fixation of the lateral flap tissue must be performed. A
4-0 polyglactin 910 suture on a semicircular needle
(e.g., P-2, ME-2, OPS-5) may be used to secure the
deep surface of the flap to the inner aspect of superolat­
eral orbital rim periosteum. However, improved eyelid
contour can be obtained by developing a periosteal flap16
from the lateral orbital rim that is left hinged at the arcus
marginalis and sutured to the inner aspect of the muscu­
locutaneous flap as far medially as possible. The perios­
teal flap must be based high enough (at least midpupil)
to provide upward pull on the lid and should be angled
superiorly 45° to follow the lower eyelid contour. It
should be 8- to 10-mm wide, and the length is deter­
mined by measuring the distance from the lateral orbital
bony rim to the lateral end of the tarsus. If necessary,
adjacent deep temporal fascia may be incorporated by
extending the periosteal incisions laterally. In all cases,
the goal is to re-create a tight eyelid with proper poste­
rior contour at the lateral canthus (Fig. 17-18).
For larger defects or for those without tarsus at the
lateral edge, it may be necessary to provide extra stability
to the lateral reconstructed lower eyelid by “backing” it
with an auricular cartilage, hard palate mucosa, or nasal
septal chondromucosal graft. Other alternatives include
AlloDerm, preserved sclera, and tarsoconjunctival graft
(see later) from the upper eyelid. Ear cartilage, hard
palate, nasal septum, or other material is obtained in the
usual manner and then cut in rectangular fashion to
snugly fit into the space between the most lateral tarsal
edge and the lateral orbital tubercle. Sutures of 5-0 poly­
glactin are then used to fix it in place at both ends. If a
periosteal flap or mucosal graft is used laterally, conjunc­
tival advancement is unnecessary. Otherwise, the muscu­
locutaneous flap (or posterior lamellar graft) should be
lined with conjunctiva by advancing it from the infero­
lateral fornix and suturing conjunctiva to the superior
skin margin of the flap with running 7-0 chromic gut or
polyglactin sutures.
After the flap has been advanced, the eyelid margin
reapproximated, and lateral support obtained, the remain­
ing incisions are closed in layers. A 5-0 or 6-0 polyglactin
suture in buried interrupted fashion is used for muscle;
6-0 polypropylene, nylon, or silk suture is used for the
skin. To prevent a standing cutaneous deformity, it may
be necessary to excise a triangle of tissue inferior to the
lid defect or to extend the skin incision required for the
flap as a gently sweeping lateral curve.
Wound dressing consists of erythromycin ophthalmic
ointment. Cotton gauze dressing is generally not neces­
sary but may help prevent hematoma. If it is used, it
should be applied carefully as a compression patch over
the closed eyelids to avoid abrading the cornea. The
patch can be removed in 1 or 2 days, and antibiotic oint­
ment is then applied to the wounds and the eye twice
daily. Erythromycin ophthalmic ointment is preferred as

402
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
it is the least likely to cause corneal irritation or allergic
reaction.
Complications of the Tenzel flap include eyelid notch­
ing, ectropion, lateral canthal webbing, trap-door defor­
mity, and symblepharon formation (Fig. 17-19).
FREE TARSOCONJUNCTIVAL GRAFTS FOR
LOWER EYELID RECONSTRUCTION
A free tarsoconjunctival graft can be used to extend the
posterior lamellar reconstruction accompanying an upper
or lower eyelid Tenzel semicircular flap. It also is an
important alternative to the semicircular flap for repair
of lower eyelid defects involving 33% to 80% of the
lower lid in some situations. It was initially described in
1918 and has been popularized more recently.17,18 The
free tarsoconjunctival graft avoids the lateral canthal
FIGURE 17-18  ■  A, Periosteal and temporalis fascial flap used to
reconstruct posterior lamella defects of temporal eyelid. Flap is
angled 45° so lower eyelid contour is maintained after strip is
reflected inferomedially. B, Periosteal inversion flap used to
support lateral lower eyelid reconstruction. Wood stick and
white arrows indicate flap elevated for repair of lower eyelid.
Note that orientation of flap provides vertical support.
A
B
FIGURE 17-19  ■  Complications of Tenzel flap. A, B, Notching of
eyelid margins. C, Trap-door deformity.
A
B
C
dissection and rearrangement that can rarely result in
deformity of the lateral aspect of the reconstructed lower
lid when the Tenzel approach is used. It has an advantage
over the Hughes tarsoconjunctival flap in that occlusion
of the eye is avoided. It requires the harvest of a free
tarsoconjunctival graft from the upper lid to repair the
posterior lamella of a lower lid defect, with concomitant
repair of the anterior lamellar defect with a musculocu­
taneous flap. A full-thickness skin graft can be used to

17  RECONSTRUCTION OF THE EYELIDS
403
inferior fornix, in which case the lid retractors should
be left recessed and only conjunctiva joined to the
tarsoconjunctival graft to avoid retraction of the graft
postoperatively.
The anterior lamella must next be reconstructed, pref­
erably with a musculocutaneous flap. This can be har­
vested from the ipsilateral upper lid or sometimes
advanced upward from below the defect. Musculocutane­
ous flaps have advantages including improved color and
texture match for the reconstructed eyelid.21
Unfortunately, there are times when the defect is
large and insufficient tissue remains to harvest a local
flap. Full-thickness skin grafts taken from the preauricu­
lar, postauricular, supraclavicular, or upper inner arm
areas are alternatives. However, there is hazard to laying
a full-thickness skin graft on top of a free tarsoconjunc­
tival graft. Because each of the grafts needs to acquire a
blood supply to survive, some vascularized tissue must
be brought between them. Orbicularis muscle is suitable
for this task and can often be mobilized to cover the
free tarsoconjunctival graft and also lay beneath the full-
thickness skin graft. A 6-0 plain suture is used to join
the orbicularis flap, the free tarsoconjunctival graft, and
the skin graft at the lid margin (see Fig. 17-20 and
video).
Potential complications from free tarsoconjunctival
grafts include dehiscence of the graft; failure of the tar­
soconjunctival graft, musculocutaneous flap, or skin graft;
persistent redness of the reconstructed lid margin22;
infections; deformity of the upper lid donor site with
buckling of the lid margin; corneal irritation from lanugo
hairs; entropion or ectropion; and ptosis or retraction of
the upper lid.
HUGHES TARSOCONJUNCTIVAL FLAP
FOR LOWER EYELID RECONSTRUCTION
Full-thickness defects will sometimes involve all or most
of the length of the lower eyelid. The Tenzel semicircular
flap is well suited for repair of smaller defects that are not
amenable to primary closure. However, larger defects
encompassing 66% to 100% of the lower eyelid are typi­
cally not satisfactorily repaired with a semicircular flap.
William Hughes first described the tarsoconjunctival
pedicle flap named for him in 1937.23 The flap provides
a relatively ideal posterior lamella replacement: vascular­
ized autogenous tarsus lined with conjunctiva (Fig.
17-21). The anterior lamella is reconstructed with a full-
thickness skin graft or a local advancement flap. Unfor­
tunately, the Hughes flap causes temporary obstruction
of vision until it is divided at a second-stage procedure,
7 to 45 days after the initial operation. Nevertheless, it
continues to be a highly effective and popular technique
for reconstruction of large lower eyelid defects.
Local anesthetic infiltration in preparation for
the Hughes tarsoconjunctival flap reconstruction must
include both the recipient bed in the lower eyelid and the
ipsilateral upper eyelid. The upper eyelid is everted, and
1 mL of local anesthetic is injected subconjunctivally
above the superior tarsal border with a 30-gauge needle.
Another 1 mL is injected subcutaneously at the eyelid
repair the anterior lamella, provided an orbicularis muscle
flap is advanced over the free tarsoconjunctival graft.19 A
musculocutaneous pedicle flap will typically result in a
better color and thickness match.
The free tarsoconjunctival graft is usually harvested
from the ipsilateral upper lid, although it is possible to
take it from the opposite upper lid, another advantage
over the Hughes and Tenzel flaps. Local anesthetic is
infiltrated into the area of the recipient lower lid defect
and at the donor upper lid subcutaneously and above the
superior tarsal border subconjunctivally. A 4-0 silk trac­
tion suture is placed in the donor upper lid margin, and
the lid is everted over a Desmarres retractor or a cotton-
tipped applicator. The desired graft is always a little
smaller than the size of the original defect, which can be
assessed by grasping both ends of residual eyelid margin
tissue and bringing them together with skin hooks or
toothed forceps. The width of the tarsoconjunctival flap
will be slightly less than the measured size of the defect,
so that there will be adequate horizontal tension in the
reconstructed eyelid after postoperative canthal tendon
relaxation to prevent late ectropion or retraction. The
average vertical tarsal height varies on the basis of race;
for whites, it is typically 10-mm in the upper lid and
4-mm in the lower lid, whereas in Asian patients these
measurements are 8-mm for the upper lid and 5-mm for
the lower lid.20 The lower 4-mm of the upper tarsus
(closest to the lid margin) must be preserved to prevent
postoperative upper lid entropion or deformity. This
works out well in most cases as only 4- to 5-mm of verti­
cal height of the free tarsoconjunctival graft is required
to replace the missing posterior lamella of the lower lid
defect. Calipers and a marking pen are used to carefully
outline the tarsoconjunctival graft before harvest. It is
best to take the graft from the central portion of the
upper lid, where the tarsus is highest, rather than to take
it from the medial or lateral areas, where the tarsal height
tapers. A No. 15 scalpel or No. 69 Beaver blade is used
to cut through conjunctiva and tarsus inferiorly and on
each end of the graft. Blunt-tipped Westcott scissors can
be used to dissect the tarsoconjunctival graft away from
the levator aponeurosis, which is left intact and disturbed
as little as possible. Superiorly it is helpful to harvest an
extra 2-mm of conjunctiva as this will help form the new
lower lid margin. Müller’s muscle is transected at the
superior tarsal border and dissected as little as possible.
Hemostasis is achieved, and the harvest site is left to heal
spontaneously (Fig. 17-20; see video).
The free tarsoconjunctival graft will have 4- to 5-mm
of vertical height centrally. It may taper medially or later­
ally, depending on the horizontal size of the graft. The
tarsoconjunctival graft is sutured to the medial and lateral
aspects of the defect with 6-0 or 7-0 silk or polyglactin
sutures, preferably with an S-14 spatula needle. It is
important to set the top of the graft at or slightly above the
residual eyelid margin. The extra conjunctiva that was
harvested from the donor lid should extend above the
reconstructed lid margin. Should the graft sit too low, an
excavation in the reconstructed eyelid in the area of the
graft may be seen postoperatively. The lower aspect of
the graft should be joined to the lower lid retractors and
conjunctiva unless the lower lid defect extends to the

404
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 17-20  ■  Lower eyelid reconstruction with autogenous tarsoconjunctival graft and local musculocutaneous transposition flap.
A, Harvest of tarsoconjunctival graft from upper eyelid, sparing the inferior 4-mm of tarsus and minimally disturbing the levator
aponeurosis. B, Placement of tarsoconjunctival graft at lower eyelid, where it is sutured to the capsulopalpebral fascia and conjunc­
tiva but not the orbital septum. C, Frontal view of tarsoconjunctival graft harvest and placement to repair posterior lamellar defect;
note that superior border of graft is oriented superiorly at lower eyelid.
A
B
C

17  RECONSTRUCTION OF THE EYELIDS
405
D
E
D, Local transposition flap harvested from upper eyelid and transposed to repair the lower eyelid anterior
lamellar defect. E, At newly reconstructed eyelid margin, union of the transposition flap and tarsoconjunctival graft with absorbable
suture.
FIGURE 17-20, cont’d  ■
crease, and proparacaine 0.5% eye drops are instilled for
corneal anesthesia.
The size of the lower eyelid defect is assessed by grasp­
ing both ends of residual eyelid margin tissue and bring­
ing them together with skin hooks or toothed forceps.
The width of the tarsoconjunctival flap is designed to be
slightly less than the measured size of the defect. This
ensures that there will be adequate horizontal tension of
the reconstructed eyelid to prevent late ectropion or
retraction after postoperative canthal tendon relaxation.
In cases requiring total lower eyelid reconstruction,
medial and lateral periosteal flaps are used for horizontal
fixation of a tarsoconjunctival flap with maximal width.
Satisfactory postoperative upper eyelid stability and
contour requires that the most inferior 4-mm of tarsus
be spared. To begin harvest of the tarsoconjunctival flap,
the upper eyelid is everted over a Desmarres or small vein
retractor (see Fig. 17-21). Calipers and a surgical marker
are used to create a line parallel to the eyelid margin
4-mm superiorly on the posterior tarsal surface.
Markings are also made for the medial and lateral borders
of the planned flap. A No. 15 scalpel or No. 69 Beaver
blade is used to make a horizontal incision along the
marked line full thickness through the tarsus only. If the
incision is partial thickness, blunt Westcott scissors can
complete the incision. In this location, the next tissue
plane encountered is the levator aponeurosis, which
should be left intact.
Dissection with blunt-tipped scissors proceeds superi­
orly in an easily maintained tissue plane at the anterior
surface of the tarsus, posterior to the levator aponeurosis.
At the superior border of the tarsus, continued dissection
in this plane will leave both Müller’s muscle and conjunc­
tiva in the flap. Although the enhanced blood supply by
including the muscle may occasionally be desirable, it is
generally a mistake to include Müller’s muscle in the flap
as upper eyelid retraction will often result after flap inset.
Instead, the plane of dissection transitions to subconjunc­
tival, posterior to Müller’s muscle. Care must be exer­
cised at the superior border of the tarsus to avoid injury

406
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
laterally. With use of an S-14 spatula needle, the flap is
sutured to the medial and lateral tarsal stumps of the
lower eyelid defect (or periosteal flaps elevated for the
purpose in total eyelid reconstruction) with multiple
interrupted 90% thickness 6-0 polyglactin sutures. The
repair should be such that the superior tarsal border
of the flap approximates the presurgical lower eyelid
margin. Conjunctiva and retractors are advanced from
the inferior fornix and secured to the lower border of the
tarsoconjunctival flap with multiple interrupted 6-0 poly­
glactin sutures. At this point, the cornea will be covered
to the vascular arcade. Transitioning from the anterior
surface of the tarsus to the new plane of dissection can
be facilitated by infiltration of 0.5 mL of local anesthetic
to hydrodynamically separate the tissues. Dissection is
then continued superiorly until the flap can be advanced
into the lower eyelid defect without excessive wound
closure tension. Cautery of conjunctival vessels is kept to
a minimum, and bipolar forceps are safest for the under­
lying cornea.
The flap will usually have 4- to 6-mm of tarsal height
centrally, with tapering of the tarsal tissue medially and
FIGURE 17-21  ■  Hughes technique for reconstruction of lower eyelid. A, Hooks used to approximate wound margins and width of
persistent defect measured. B, Three-sided flap consisting of conjunctiva and tarsus incised. Horizontal border of flap is at least
4-mm superior to lid margin. C, Composite flap is advanced into lower eyelid defect so that the upper border of tarsus contained
within the flap is in alignment with remaining lower eyelid margin. D, Anterior lamella reconstructed with full-thickness skin graft.
Superior border of skin graft is sutured to conjunctiva 1- to 2-mm above upper border of tarsus contained within tarsoconjunctival
flap. E, Pedicle of tarsoconjunctival flap divided 2 to 4 weeks after initial reconstruction.
A
B
C
D
E

17  RECONSTRUCTION OF THE EYELIDS
407
the levator aponeurosis with absorbable suture. The eye
is dressed with ophthalmic antibiotic ointment (e.g.,
erythromycin) or antibiotic eye drops, and the patient is
instructed to continue use twice daily for 1 week. Exam­
ples of eyelid reconstruction by the Hughes tarsocon­
junctival flap are shown in Figure 17-22.
Potential complications from Hughes tarsoconjuncti­
val flap repair with full-thickness skin graft include failure
of the skin graft, dehiscence of the tarsoconjunctival
flap,28 infections, persistent erythema of the reconstructed
lower eyelid margin, corneal irritation from lanugo hair
trichiasis, pyogenic granuloma, lower and upper eyelid
retraction, notching of the reconstructed eyelid, sym­
blepharon, entropion, ectropion, and upper eyelid ptosis
(Fig. 17-23).
TARSAL TRANSPOSITION FLAP FOR
LATERAL UPPER EYELID RECONSTRUCTION
Defects involving up to 50% of the upper eyelid can be
closed with a tarsoconjunctival transposition flap, as ini­
tially described by Kersten et al29 in 1986. It is possible
to combine it with a flap of periosteum from the lateral
orbital rim to repair larger defects. It is a viable alterna­
tive to composite grafts, Tenzel semicircular flaps, and
even the Cutler-Beard repair in lateral upper lid defects.
It has the advantage of being a one-stage repair, using
local vascularized eyelid tissue rather than grafts from the
nose, ears, or other eyelids. It involves use of the ipsilat­
eral remaining upper lid tarsus as a transposition flap to
repair the posterior lamellar defect, followed by a mus­
culocutaneous flap or skin graft for the anterior lamella.
The technique begins with local anesthetic adminis­
tration to the involved upper lid subcutaneously, at the
superior conjunctival fornix, and at the lateral canthus. A
4-0 silk traction suture is placed in the lid margin and
used to evert the lid over a cotton-tipped applicator. An
incision is planned in the remaining tarsus of the upper
lid. A vertically oriented flap 3- to 4-mm wide and hinged
at the eyelid margin is designed with a caliper and out­
lined with a marking pen. A No. 15 blade is used to incise
conjunctiva and tarsus from the top of the tarsus to within
1.5- to 2-mm of the lid margin, after which the flap is
sharply dissected free from its anterior attachments to the
orbicularis oculi. The flap is then pivoted 90°. After
transposition, there will be some tissue bunching at the
lid margin, which can be carefully trimmed with fine
scissors. The flap is sutured to the remaining soft tissue
at the lateral canthus, or to a periosteal flap, with a 5-0
polyglactin suture on an S-14 spatula needle. The suture
technique is important as dehiscence of this flap could
lead to failure of the repair. A “crossed swords” method
in which the two spatula needles of a double-armed
suture are both passed through the tarsoconjunctival flap
works well. Good purchase at the anchor point and
avoidance of excessive tension on the flap are both impor­
tant. The conjunctiva can usually be advanced to the
superior border of the tarsoconjunctival transposition
flap from the superior fornix and loosely fixed there with
7-0 chromic suture on a spatula needle. Existing attach­
ments of the remaining levator aponeurosis are usually
and protected by the tarsoconjunctival flap and the upper
eyelid will rest at approximately midpupil height.
Next, the anterior lamella must be reconstructed with
a full-thickness skin graft or musculocutaneous advance­
ment flap. Use of bipedicle orbicularis flaps or a muscu­
locutaneous advancement flap for the anterior lamella has
advantages including improved color and texture unifor­
mity and postoperative neurologically active muscle in
the lower eyelid24 that may prevent retraction. Often,
however, there is inadequate local tissue for such flaps,
and a full-thickness skin graft is necessary. Donor sites
for skin grafts most commonly used include the ipsilateral
or contralateral upper eyelid, preauricular25 or postau­
ricular skin, and supraclavicular skin. A template is devel­
oped to estimate the size of the required skin graft to
include coverage of the tarsoconjunctival flap up to the
desired height of the reconstructed eyelid. The full-
thickness graft is harvested in the usual way, thinned of
connective tissue and fat, and sutured to the recipient
site. Running 6-0 or 7-0 chromic gut is used for the
superior border of the graft, with fixation to the conjunc­
tiva just above the superior tarsal border. Fixation at the
medial, lateral, and inferior borders can be accomplished
with the same suture, but 6-0 silk is preferred because it
can be used to easily create a tie-over bolster (e.g., cotton
dental roll, Telfa, and cotton wool). Alternatively, an
ocular compression patch left in place for 36 to 48 hours
has also been effective in ensuring success of the skin
graft.
Postoperatively, the patient is instructed to use oph­
thalmic antibiotic drops (e.g., gentamicin, ciprofloxacin)
applied to the eye and bolster, if one is present, four times
daily. Because peripheral vision is obviously reduced, use
of a metal eye shield is helpful to avoid inadvertent injury
to the flap, graft, and involved eye from blunt trauma.
Chromic sutures are left to dissolve, but silk sutures are
typically removed at 1 week.
Inset of the tarsoconjunctival flap is commonly per­
formed at 2 to 4 weeks26 after the initial reconstruction,
although reports indicate successful results as early as 1
week.27 This second stage is performed with topical
proparacaine 0.5% eye drops and 1% lidocaine with
1 : 200,000 epinephrine concentration for local anesthe­
sia. A narrow malleable retractor or a grooved director is
inserted under the flap to protect the cornea. The flap is
separated at the intended position of the new lower eyelid
margin with scissors or a No. 15 scalpel, angled to leave
a small conjunctival frill on the lower eyelid. The new
lower eyelid margin is trimmed of excess tissue as needed,
and gentle hemostasis is achieved. The ideal position for
the mucocutaneous junction that will form with healing
is just anterior to the apex of the reconstructed eyelid so
that the keratinized skin and lanugo hairs of the graft do
not contact the cornea. It may be helpful to suture the
conjunctival edge anteriorly with 7-0 chromic gut. The
remaining flap tissue still attached to the upper eyelid is
transected flush with the conjunctival surface while the
eyelid is everted, and hemostasis is achieved. If Müller’s
muscle has been included in the flap, adjustment in upper
eyelid height and contour may be necessary. This is
accomplished with blunt dissection superiorly on the
anterior surface of Müller’s muscle and then fixation to

408
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 17-22  ■  Hughes tarsoconjunctival flap reconstruction. A, Squamous cell carcinoma of left lower eyelid. B, Same patient as
shown in A with 95% loss of lower eyelid after resection of cancer. C, Postoperative view 1 year after reconstruction with Hughes
flap and skin graft. D, Morpheaform basal cell carcinoma of right lower eyelid. E, Same patient as shown in D before separation of
Hughes flap. F, Postoperative view 6 months after reconstruction with Hughes flap and skin advancement flap.
A
B
C
D
E
F

17  RECONSTRUCTION OF THE EYELIDS
409
adequate for eyelid elevation so that manipulation of the
levator is not necessary. The residual anterior lamellar
defect can sometimes be repaired with a musculocutane­
ous advancement flap from the lateral aspect of the upper
lid. If this is not possible, a full-thickness skin graft can
also be used (Figs. 17-24 and 17-25; see video).
Potential complications include dehiscence of the tar­
soconjunctival transposition flap, irregularity or notching
of the reconstructed lid margin, upper eyelid retraction
or ptosis, and failure of the musculocutaneous flap or skin
graft.
EYELID AND SIMPLE TARSAL
COMPOSITE GRAFTS
Composite grafts can be harvested from the contralateral
upper or lower eyelid to provide similar autologous tissue
for reconstruction. The primary disadvantage of this
approach is violation of the integrity of the normal eyelid.
Composite grafts of tarsus and conjunctiva can be used
for posterior lamellar reconstruction alone,18 or alterna­
tively, composite grafts of conjunctiva, tarsus, and skin
including the lid margin30,31 can be used with an inter­
posed blood supply to reconstruct short segments of the
upper or lower eyelid. Microsurgical transfer of full-
thickness eyelid free flaps has also been described in a
rabbit model.32
FIGURE 17-23  ■  Complications of Hughes flap reconstruction.
A, Granuloma. B, Left upper eyelid retraction.
A
B
FIGURE 17-24  ■  Upper eyelid reconstruction with tarsal transpo­
sition flap. A, Superior border of lateral tarsus incised horizon­
tally. B, Vertical tarsal incision creates an inferiorly based
transposition flap. C, Flap fixed to lateral orbital rim or lateral
canthal tendon.
A
B
C

410
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
Free tarsoconjunctival grafts can be harvested from
the contralateral upper eyelid and used to reconstruct
defects up to two-thirds the width of the posterior lamella
of the ipsilateral upper eyelid or either lower eyelid. The
graft is obtained by use of techniques previously described.
The graft is transferred to the defect and secured to the
remaining eyelid tarsus with interrupted partial-thickness
5-0 or 6-0 polyglactin sutures so that it is perfectly aligned
and a 2-mm-wide conjunctival free edge is positioned at
the lid margin. If necessary, 4-0 polyglactin is used to
attach the lateral edge of the graft to the lateral canthal
tendon or to the periosteum inside the lateral orbital rim.
The anterior lamella is then reconstructed with a muscu­
locutaneous advancement flap (e.g., semicircular flap or
transposition flap as described before).
In cases in which the full-thickness lower eyelid defect
is shallow (e.g., 5- to 10-mm in height) and there is sub­
stantial lack of skin laxity for the creation of a flap, a modi­
fied composite eyelid graft can be useful. This graft
consists of a pentagon of full-thickness eyelid harvested
from the contralateral upper or lower eyelid from which
the orbicularis muscle has been excised, leaving the skin,
lashes, tarsus, and conjunctiva (Figs. 17-26 and 17-27). Its
width is limited by the laxity in the donor eyelid, but typi­
cally at least 10-mm can be harvested in elderly patients.
The graft is supported by the rich blood supply of adjacent
orbicularis muscle that is mobilized into the space left by
the excised muscle. The donor defect is closed according
to the method described in the section discussing primary
closure of full-thickness defects. The eyelid composite
graft is transferred to the defect, and the tarsal edges are
sutured in perfectly aligned position with partial-thickness
5-0 or 6-0 polyglactin interrupted sutures. Adjacent orbi­
cularis muscle, typically from the inferior wound edge, is
undermined and sutured into the space between the skin
and tarsus with 6-0 polyglactin. The skin edges of the graft
are then sutured to the borders of the recipient site with
6-0 silk, and a bolster or compression patch is applied over
the closed lids for 24 to 36 hours.
CUTLER-BEARD FLAP FOR COMPLETE UPPER
EYELID RECONSTRUCTION
Large defects of the upper eyelid can be challenging for
the reconstructive surgeon because upper lid anatomy
FIGURE 17-25  ■  Tarsal transposition flap reconstruction of the right upper eyelid. A, Mucinous eccrine gland carcinoma. B, Six months
after reconstruction.
A
B
and function are complex. For maintenance of corneal
integrity, crisp vision, and patient comfort, the upper
eyelid must have a 5- to 10-mm range of movement and
a dynamic blink. Restoration commonly requires a mul­
tistage approach in which an approximation of the normal
tissues is first reconstructed, and then movement in pro­
traction and retraction are added as required for vision
and comfort. No single operation satisfactorily achieves
all of the patient’s and surgeon’s goals when the defect is
very large.
The Cutler-Beard lid-sharing flap33 is probably the
best available technique for total upper eyelid reconstruc­
tion. It is a skin-muscle-conjunctiva flap from the lower
eyelid advanced into the upper eyelid defect. It involves
temporary closure of the involved eye for 4 to 6 weeks
(Fig. 17-28). The other major disadvantage of this flap is
that the rigid posterior lamella is not usually replaced,
which may result in instability of the reconstructed eyelid
margin over time.34 Free tarsoconjunctival grafts (as
described earlier) or free autogenous hard palate mucosal
grafts35,36 can be used to provide posterior lamellar
support to the flap37 but are best added after flap inset so
that corneal integrity can be monitored while risk of
suture injury exists.
The edges of the upper eyelid defect are freshened
to make them perpendicular to any remaining eyelid
margin, and the horizontal width of the defect is mea­
sured while the edges are brought toward one another
with skin hooks. Next, a horizontal line is drawn on the
lower eyelid skin parallel to the lid margin but 5-mm
inferior to permit an intact blood supply to the lower
eyelid margin. This line is drawn 2-mm longer than the
defect width, and then vertical lines are drawn extend­
ing inferiorly from either end for 15- to 20-mm. A 4-0
silk suture on a G-1 cutting needle is passed in a coronal
plane through the gray line of the lower eyelid in two
locations to serve as a traction suture. With the lid
pulled superiorly over a Jaeger plate or similar lid guard
protecting the globe, a No. 15 scalpel blade is used to
make a full-thickness horizontal blepharotomy along
the horizontal line. Straight scissors are used to create
the vertical incisions that are carried to the inferior
conjunctival fornix. Further inferiorly, the skin and
orbicularis are undermined to create a composite
advancement flap that includes conjunctiva and lower
eyelid retractors.

17  RECONSTRUCTION OF THE EYELIDS
411
FIGURE 17-26  ■  A, Modified composite graft consisting of skin, lashes, tarsus, and conjunctiva. Muscle removed to accommodate
muscle advancement flaps at recipient site to nourish graft. B, Bilateral muscle flaps advanced into space left by excision of muscle
of graft. Skin and lashes of graft are hinged to graft superiorly. C, Graft sutured in place. Donor site closed primarily.
B
A
C
The composite flap is then brought under the bridge
of lower eyelid margin and sutured to the edges of the
upper eyelid defect. The conjunctiva and lower eyelid
retractors are sutured with 6-0 polyglactin to the rem­
nants of tarsus or to the canthal tendons or periorbita
medially and laterally. The borders of the orbicularis and
skin are also approximated in layers with 6-0 polyglactin
suture.
Flap inset is typically accomplished as a second stage
4 to 8 weeks after reconstruction, although successful
inset at 2 weeks has been described.38 A longer time may
be necessary for tissue vascularization and stretching in
patients who have had local irradiation or who have par­
ticularly tight wound closures. A horizontal mark is made
on the skin 2-mm below the anticipated new upper eyelid
margin. With the cornea protected by a narrow malleable
retractor, the flap is cut with straight scissors angled so
that the cut is more inferior on the conjunctival side.
After initial hemostasis, the conjunctival edge is then
sutured to the skin edge with 7-0 chromic suture, ensur­
ing that the new upper eyelid margin is not keratinized.
It may be necessary to excise a small wedge of orbicularis
muscle to permit advancement of the conjunctival edge
anteriorly. The inferior edge of the lower eyelid bridge
is then freshened, and the base of the lower eyelid flap is
sutured to the bridge in a layered fashion with buried
interrupted 6-0 polyglactin for the conjunctiva and
retractors and interrupted or running 6-0 polypropylene,

412
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 17-27  ■  Reconstruction of eyelid with composite graft. A, Defect. B, Repair with composite graft to right upper eyelid. Lower
eyelid repaired with rotation advancement skin flap and periosteal flap. C, Composite graft harvest site from left lower eyelid.
D, Postoperative view at 2 months. Note preservation of lashes and maintenance of margin of upper lateral eyelid.
A
B
C
D
FIGURE 17-28  ■  Cutler-Beard flap reconstruction of upper eyelid. A, Flap designed on lower eyelid. B, Posterior lamellar graft in place.
C, Clinical appearance at surgery. D, After inset of flap.
A
B
C
D

17  RECONSTRUCTION OF THE EYELIDS
413
(Figs. 17-29 and 17-30). The probes should first be bent
so that each forms a semicircle; this greatly facilitates
retrieval from the inferior nasal meatus. One probe is
then inserted into the proximal end of each remaining
canaliculus or punctum. One at a time, each probe is then
passed into the lacrimal sac until a firm “stop” is felt on
the lacrimal bone. It is then redirected inferolaterally
while gentle medial pressure is maintained. The probe
will pass into the nasolacrimal duct and ultimately into
the inferior nasal meatus, from which it is retrieved under
headlight observation with a Crawford hook, Takahashi
nylon, or plain gut for the skin. The skin and orbicularis
may need to be undermined to prevent lower eyelid
ectropion, and any horizontal laxity should be repaired
with a lateral tarsal strip procedure.
CANALICULAR RECONSTRUCTION
Defects in the medial upper and lower eyelids or medial
canthus will frequently involve the lacrimal drainage
system, especially the puncta and canaliculi. Primary
reconstruction of these tissues will often prevent epiphora
and the need for more extensive procedures, such as con­
junctivodacryocystorhinostomy with Jones tube. In cases
involving loss of the punctum and partial proximal cana­
liculus, simple monocanalicular or bicanalicular silicone
lacrimal intubation may be adequate to maintain lacrimal
drainage. However, complete loss of the canaliculi is dif­
ficult to manage primarily, and postoperative epiphora
may be best prevented in these cases by primary endo­
scopic conjunctivodacryocystorhinostomy with Jones
tube,39 performed in conjunction with an ophthalmologist
familiar with that procedure.
In cases in which there is only partial loss of the cana­
liculi or puncta, silicone intubation of the remaining
lacrimal system should be performed.40,41 The Quickert-
Dryden malleable silver probes and the Crawford
olive-tipped probes attached to silicone tubing are com­
monly available and relatively easy to use for this purpose
FIGURE 17-29  ■  Silicone tubing for lacrimal intubation with Craw­
ford probes.
FIGURE 17-30  ■  Lacrimal drainage system.
Nasolacrimal duct
Lacrimal sac
Lacrimal canaliculi

414
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
16. Weinstein GS, Anderson RL, Tse DT, et al. The use of a periosteal
strip for eyelid reconstruction. Arch Ophthalmol 1985;103:357.
17. Leone CR, Hand SI. Reconstruction of the medial eyelid. Am J
Ophthalmol 1979;87:797.
18. Hawes MJ. Free autogenous grafts in eyelid tarsoconjunctival
reconstruction. Ophthalmic Surg 1987;18:37.
19. Paridaens D, van den Bosch WA. Orbicularis muscle advancement
flap combined with free posterior and anterior lamellar grafts.
Ophthalmology 2008;115:189.
20. Wesley RE, McCord CD, Jones NA. Height of the tarsus of the
lower eyelid. Am J Ophthalmol 1980;90:102.
21. Leone CR, Van Gemert JV. Lower lid reconstruction using tarso­
conjunctival grafts and bipedicle skin-muscle flap. Arch Ophthal­
mol 1989;107:758.
22. Hawes MJ, Grove AS, Hink EM. Comparison of free tarsoconjunc­
tival grafts and Hughes tarsoconjunctival flaps for lower eyelid
reconstruction. Ophthal Plast Reconstr Surg 2011;27:219.
23. Hughes WL. A new method for rebuilding a lower lid. Arch Oph­
thalmol 1937;17:1008.
24. Lowry JC, Bartley GB, Litchy WJ. Electromyographic studies of
the reconstructed lower eyelid after a modified Hughes procedure.
Am J Ophthalmol 1995;119:225.
25. Dryden RM, Wulc AE. The preauricular skin graft in eyelid recon­
struction. Arch Ophthalmol 1985;103:1579.
26. McNab AA. Early division of the conjunctival pedicle in modified
Hughes repair of the lower eyelid. Ophthalmic Surg Lasers
1996;27:422.
27. Leibovitch I, Selva D. Modified Hughes flap: division at 7 days.
Ophthalmology 2004;111:2164.
28. Bartley GB, Messenger MM. Outcome of tarsoconjunctival flap dehis­
cence after eyelid reconstruction. Am J Ophthalmol 2002;134:627.
29. Kersten RC, Anderson RL, Tse DT, Weinstein GL. Tarsal rota­
tional flap for upper eyelid reconstruction. Arch Ophthalmol
1986;104:918.
30. Putterman AM. Viable composite grafting in eyelid reconstruction.
Am J Ophthalmol 1978;85:237.
31. Werner MS, Olson JJ, Putterman AM. Composite grafting for
eyelid reconstruction. Am J Ophthalmol 1993;116:11.
32. Molnar JA, Yan JG, Matloub HS. A prefabricated free flap for
eyelid reconstruction. J Reconstr Microsurg 1998;14:479.
33. Cutler NL, Beard C. A method for partial and total upper eyelid
reconstruction. Am J Ophthalmol 1955;39:1.
34. Carrol RP. Entropion following the Cutler-Beard procedure. Oph­
thalmology 1983;90:1052.
35. Siegel RJ. Palatal grafts for eyelid reconstruction. Plast Reconstr
Surg 1985;76:411.
36. Bartley GB, Kay PP. Posterior lamellar eyelid reconstruction with
a hard palate mucosal graft. Am J Ophthalmol 1989;107:609.
37. Fischer T, Noever G, Langer M, Kammer E. Experience in upper
eyelid reconstruction with the Cutler-Beard technique. Ann Plast
Surg 2001;47:338.
38. Hsuan J, Selva D. Early division of a modified Cutler-Beard flap
with a free tarsal graft. Eye (Lond) 2004;18:714.
39. Trotter WL, Meyers DR. Endoscopic conjunctivodacryocystorhi­
nostomy with Jones tube placement. Ophthalmology 2000;107:
1206.
40. Quickert M, Dryden RM. Probes for intubation in lacrimal drain­
age. Trans Am Acad Ophthalmol Otolaryngol 1970;74:431.
41. McCord CD. Canalicular resection and reconstruction by canalicu­
lostomy. Ophthalmic Surg 1980;11:440.
forceps, or other clamp. If the semicircular curve created
before passage is ideal, the probe will often spontaneously
exit from the naris. Once both ends have been passed in
this fashion, the probes are cut from the silicone, and the
two silicone ends are tied together with a square knot so
that there is neither tension at the medial canthus nor a
prolapse of the knot from the nostril. It can be fixed to
the lateral nasal wall with 6-0 polypropylene suture or
tied over a small silicone bolster to avoid excessive move­
ment, but the surgeon must be careful to avoid tension
at the medial canthus that will invariably cause undesired
erosion of the remaining canaliculi. The silicone tubing
is typically left in place at least 6 months. It can be
removed by cutting the tube in the medial ocular com­
missure and then pulling sharply on one end or, if it is
fixated in the nose, by pulling the knot out from the
inferior nasal meatus.
REFERENCES
1. Elner VM. The histologic anatomy of the medial canthal ligament
and surrounding structures. Annual meeting of the American
Society of Ophthalmic Plastic and Reconstructive Surgery. New
Orleans. October 28, 1989.
2. Anderson RL. Medial canthal tendon branches out. Arch Ophthal­
mol 1977;95:2051.
3. Grabb WC, Smith JW. Plastic surgery. 3rd ed. Boston: Little,
Brown; 1979.
4. Patrinely JR, Marines HM, Anderson RL. Skin flaps in periorbital
reconstruction. Surv Ophthalmol 1987;31:249.
5. Shotton F. Rhombic flap for medial canthal reconstruction. Oph­
thalmic Surg 1973;14:46.
6. Doxanas MT, Anderson RL. Clinical orbital anatomy. Baltimore:
Williams & Wilkins; 1984.
7. Callahan MA, Callahan A. Ophthalmic plastic and orbital surgery.
Birmingham: Aesculapius; 1979.
8. Lowry JC, Bartley GB, Garrity JA. The role of second-intention
healing in periocular reconstruction. Ophthal Plast Reconstr Surg
1997;13:177.
9. Sharkar J, Nair RG, Sullivan SC. Management of peri-ocular skin
tumours by laissez-faire technique: analysis of functional and cos­
metic results. Eye (Lond) 2002;16:50.
10. Anderson RL, Gordy DD. The tarsal strip procedure. Arch Oph­
thalmol 1979;97:2192.
11. Anderson RL, Ceilley RI. A multispecialty approach to the excision
and reconstruction of eyelid tumors. Ophthalmology 1978;85:
1150.
12. Stabel JE, Hawes MJ. The arrowhead skin-muscle flap in the
closure of lower eyelid defects. Ophthal Plast Reconstr Surg
1998;14:222.
13. Tenzel RR, Stewart WB. Eyelid reconstruction by the semicircle
flap technique. Ophthalmology 1978;85:1164.
14. Mustarde JC. Repair and reconstruction in the orbital region. New
York: Churchill Livingstone; 1971.
15. Foster JA, Scheiner AJ, Wulc AE, et al. Intraoperative tissue expan­
sion in eyelid reconstruction. Ophthalmology 1998;105:170.

415
C H A P T E R 1 8 
RECONSTRUCTION OF THE NOSE
Shan R. Baker
INTRODUCTION
During the last decade, reconstruction of the nose has
reached a high level of sophistication with enhancement
of aesthetic results.1-3 This has been achieved by empha­
sizing the necessity of replacing surgically ablated tissue
with like tissue. Skin is replaced with skin that matches
in color and texture as closely as possible. Cartilage and
bone are replaced, and mucosa is used to replace any loss
of the nasal lining. The concept of nasal aesthetic units
has emerged with an emphasis on replacing the skin of
an entire unit if the majority of the skin is missing.
Another important concept that has led to enhancement
in the results of restorative surgery has been the emphasis
on the placement of incisions for local flaps along borders
of aesthetic regions or units to maximize camouflage of
scars. Whenever possible, local flaps are designed so that
they are not transferred across the borders of aesthetic
regions, particularly if the border has a concave topogra­
phy. An example of such a border is the alar-facial sulcus,
which represents a concave border between three
aesthetic facial regions: the nose, the cheek, and the
upper lip.4,5
TOPOGRAPHIC ANALYSIS
Assessment of the external nose requires an appreciation
of the relationship between the nose and the rest of the
face. On the frontal view, the face is divided into hori­
zontal thirds. The upper third begins at the anterior
hairline and ends at the glabella. The middle third extends
from the glabella to the subnasion. The lower third
extends from the subnasion to the menton. Nasal height
is measured from the radix to the subnasion and should
represent 47% of the height of the face from the menton
to the radix. In the vertical plane, the face is divided into
fifths. Ideally, the width of each division equals the hori­
zontal width of a single palpebral aperture. Ideally, the
nasal base, which is the distance between the alar-facial
sulci, is equal to the intercanthal distance and represents
one fifth of the facial width. The nose occupies the central
third of the face in the vertical axis and the central fifth
in the horizontal axis and thus should lie precisely in the
midline of the face. On the frontal view, a gentle, curved,
unbroken line emanates from the eyebrow and courses
along the lateral border of the dorsum to end at the tip-
defining point.
The aesthetic proportions of the ideal nasal shape and
size have been established. On the lateral view, the dis­
tance from the vermilion border of the upper lip to the
subnasale is equal to the distance from the subnasale to
the pronasale.6 The distance from the alar-facial sulcus
to the midpoint of the nares ideally equals that from the
midpoint to the caudal edge of the nasal tip. On the
lateral view, a right-angle triangle with the ratios of its
sides being 3 : 4 : 5 and the vertices being at the nasion,
alar-facial sulcus, and tip has been described to illustrate
the ideal nasal proportions and size.7 Figure 18-1 illus­
trates the standard directional nomenclature.
FACIAL AESTHETIC REGIONS
The face can be divided into topographic regions, each
with its individual intrinsic characteristics of skin color,
texture, contour, and hair growth.5 Each has an individual
shape created by the underlying facial skeleton. The nose
is one of the aesthetic regions of the face and may be
divided into several aesthetic units (Fig. 18-2). Each unit
may be proportionally overdeveloped or underdeveloped
relative to other noses, but there is a consistent general
configuration from nose to nose. There are nine aesthetic
units of the nose identified by distinctive convex or
concave surfaces, including the nasal tip (lobule), dorsum,
paired sidewalls, paired alae, paired soft tissue facets, and
columella. In general, the shape of the tip is determined
by the size and contour of the alar cartilages and specifi­
cally by the domal portion of the nasal cartilages. It is
covered by relatively thick skin containing many seba­
ceous glands (sebaceous skin). Each dome causes a point
of reflected light. Above the tip is a supratip depression
that separates the tip from the dorsum. The skin of the
dorsum tends to be less thick and sebaceous than the skin
of the tip, becoming progressively thinner as it ascends
to the rhinion and thickening again as it approaches the
glabella. The nasal bones together with the upper lateral
cartilages and cartilaginous septum provide skeletal
support for the dorsum. The lateral borders of the dorsum
are defined by the lateral shoulders of the upper lateral
cartilages and the junction of the nasal bones with the
frontal processes of the maxillae. These structures sepa­
rate the dorsum from the sidewalls and create a line of
reflected light and shadows separating the lateral walls
from the dorsum. The nasal sidewalls are most often a
combination of convex and concave elements extending
 Videos available online

416
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 18-1  ■  Directional nomenclature of nose. (From Jewett BS: Anatomic considerations. In Baker SR, editor: Principles of nasal
reconstruction, ed 2, New York, Springer, 2011.)
Cephalic
Caudal
Anterior
Posterior
Medial
Lateral
FIGURE 18-2  ■  A, B, Aesthetic units of nose. Blue represents thin-skinned regions; red represents regions of thicker skin. (From Jewett
BS: Anatomic considerations. In Baker SR, editor: Principles of nasal reconstruction, ed 2, New York, Springer, 2011.)
A
B

18  RECONSTRUCTION OF THE NOSE
417
laterally from the dorsum to the junction of the nose with
the cheek. Structurally, the sidewalls are supported by the
lateral extensions of the nasal bones and upper lateral
cartilages and the medial extension of the frontal pro­
cesses of the maxillae. The skin of the sidewalls is thin
and contains fewer sebaceous glands than that of the
dorsum and tip; it is separated from the ala by the alar
groove, which is the deepest contour line of the nose.
This groove is continuous laterally with the alar-facial
sulcus, and together they circle the alae, delineating them
from the tip, sidewalls, and cheeks. The alar unit itself is
a smooth bulge reflecting a single spot of light and is
covered with thick skin similar in texture and porosity to
the skin of the tip. The structural support of the ala is
provided by thick fibrofatty tissue that does not contain
cartilage.
The soft tissue facets contribute to a portion of the
nostril margin and span the angle between intermediate
and lateral crura of each lower lateral cartilage. They are
covered by thin, nonsebaceous skin and have only a small
amount of fibrous connective tissue for structural support.
They are separated as distinct units from the tip by the
caudal border of the intermediate crura. The columella,
like the tip and dorsum, is a nonpaired aesthetic unit
extending from the caudal aspect of the tip to the upper
lip. It is covered by the thinnest of nasal skin and structur­
ally is supported by the medial crura. The lining for each
of the nine aesthetic units of the nose is also distinctive.
Thin non–hair-bearing skin lines the tip; the soft tissue
facets and alae are lined by thicker skin, the caudal aspect
of which is hair bearing. The columella is backed by the
membranous septum, which is skin lined. At the piriform
aperture, the lining transitions to mucosa, which lines the
dorsum and sidewall units.
Menik has stressed that the goal of restorative nasal
surgery is not simply to fill a defect.2 Depending on the
extent of the defect, wounds should be altered in size,
configuration, and depth to allow reconstruction of an
entire unit. If the majority of the surface area of a unit is
lost, resurfacing of the entire unit is usually preferable.
This is accomplished by discarding the remaining skin of
the unit and designing the covering flap so it will com­
pensate for the discarded skin. This arrangement places
scars at the junction between units, where they will lie in
depressions or along shadow lines, maximizing scar cam­
ouflage. In these junctions, scars blend with normal
contour lines of the nose and distract the viewing eye.
Resurfacing of an entire aesthetic unit causes a mild trap-
door scar contraction phenomenon, which in turn causes
the entire unit to bulge slightly, simulating the normal
convexity of the tip and alae.2 The columella, dorsum,
and sidewalls are not convex, and I do not routinely
resurface the entire surface of these aesthetic units when
defects occupy more than half of their entire surface area.
An aesthetic nasal unit that is to be entirely resurfaced
is covered with a flap that exactly duplicates its surface
area and pattern whenever possible. A fresh wound is
always enlarged by retraction of its margins; thus, the
contralateral unit should be used to design covering flaps.
If the contralateral counterpart is missing or a unit does
not have a matching pair, a template replicating the ideal
unit size for that specific patient is used. The nose is a
three-dimensional structure and reconstruction of each
unit must duplicate the normal contour. This is accom­
plished by concomitantly integrating structural support
in each step of the repair. Reconstructed skeletal ele­
ments are attached to a stable foundation, such as remain­
ing nasal cartilages or the bone of the maxilla, to prevent
collapse or distortion of the unit during the healing
process.2 Within the defect, the constructed skeletal
structures are designed to completely span the defect.
This is accomplished before wound healing to prevent
distortion from scar contraction during the healing
process.
Application of the aesthetic unit principles provides a
logical cognitive approach to nasal reconstruction.
Missing tissue must be replaced with like tissue in a quan­
tity and quality that exactly replicates the pattern, surface
area, and contour of the absent unit.
LINING FLAPS
The vascular supply to the internal nose is shown in
Figure 18-3. On the basis of the vascular anatomy, Burget
and Menik have demonstrated that the entire ipsilateral
septal mucoperichondrium can be transferred with a
narrow pedicle containing the septal branch of the supe­
rior labial artery.1 Likewise, the entire contralateral
mucoperichondrium can be turned laterally as a dorsally
based hinge flap based on the anterior and posterior
ethmoid arteries to line the sidewall of the nose.1 Burget
and Menik have also shown that if both right and left
septal branches are included in the pedicle, the entire
septum can be rotated out of the nasal passage as a com­
posite flap containing a sandwich of cartilage between the
two mucoperichondrial leaves.1 Such flaps, whether they
are composite or simple mucoperichondrial hinge flaps,
can be designed to extend from the floor of the nose to
within 1 cm of the junction of the upper lateral cartilage
and cartilaginous septum. The flaps may extend posteri­
orly well beyond the bone-cartilage junction of the
septum, producing a hinged mucosal flap measuring as
much as 3 cm wide and 5 cm long.1 Burget and Menik
advocate a back cut of the mucosa in the area of the
anterior septal angle to facilitate flap transfer.3 I prefer to
leave the flap hinged on the entire length of caudal
septum to maintain a wider pedicle and to enhance the
vascularity of the flap. These authors have also described
a bipedicle flap of vestibular skin and mucosa based medi­
ally on the septum and laterally on the floor of the nasal
vestibule. Such a flap may be elevated away from the
undersurface of the lateral crus and mobilized inferiorly
to reline alar defects. All of these lining flaps have a reli­
able vascularity and are thin and supple, providing natural
physiologic material for the interior of the nasal passage.
Bipedicle Vestibular Skin Advancement Flap
Lining for full-thickness alar or unilateral tip defects that
have a vertical dimension (caudal to cephalic) of 1.0 cm
or less can be provided by the thin skin of the remaining
nasal vestibule. Defects with vertical dimensions as large
as 1.5 cm may sometimes be lined by this method if the

418
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 18-3  ■  Arterial blood supply of left septum (A) and right lateral wall (B) of nasal cavity. (From Jewett BS: Anatomic consider­
ations. In Baker SR, editor: Principles of nasal reconstruction, ed 2, New York, Springer, 2011.)
A
Kiesselbach’s
plexus
Septal branch of
superior labial a.
Medial internal nasal branch of
anterior ethmoidal a.
Septal branch of
posterior ethmoidal a.
Posterior septal branch of
sphenopalatine a.
B
External nasal branch
of anterior ethmoidal a.
Branch of
angular a.
Lateral internal nasal branch of
anterior ethmoidal a.
Lateral branch of
posterior ethmoidal a.
Sphenopalatine a.
Descending
palatine a.
Lesser palatine a.
Greater palatine a.

18  RECONSTRUCTION OF THE NOSE
419
fibrofatty tissue of the ala are left intact. As the flap is
advanced caudally, redundancy occurs near the caudal
aspects of the medial and lateral pedicles. This represents
the standing cutaneous deformities that form with all
advancement flaps. The tissue redundancy should not be
trimmed because it will dissipate during wound healing.
In the case of full-thickness defects that extend through
the margin of the nostril, the flap is positioned so that
the caudal border extends 1- to 1.5-mm below the infe­
rior aspect of the framework used to reinforce the nostril
margin. This enables the inferior border of the covering
flap to be sutured to the vestibular skin flap, restoring the
delicate nostril margin. When the lining defect does not
extend through the nostril margin, the caudal border of
the flap is sutured to the caudal border of the lining
defect. Structural support for the flap is provided by
septal or auricular cartilage grafts. The flap is suspended
to the overlying cartilage grafts with 5-0 polydioxanone
sutures (see Fig. 18-4). The sutures pass from the external
surface of the cartilage graft, through cartilage and flap,
and back through the flap and overlying cartilage. Three
or four loosely tied sutures are usually required to support
the flap and to suspend it completely to the framework.
remaining skin of the lower nasal vault is of sufficient size.
Before the bipedicle flap is created, the vertical height of
the remaining vestibular skin is measured to ensure that
there will be sufficient width for the flap to cover the
lining defect. An extended intercartilaginous incision is
made between the lateral crus and caudal aspect of the
upper lateral cartilage. The incision extends from the
anterior septal angle to the most lateral aspect of the floor
of the vestibule. The remaining vestibular skin is then
mobilized caudally in the form of a bipedicle advance­
ment flap by elevating it away from the overlying lateral
crus (Fig. 18-4).8 Dissection of the flap is assisted by
hydrodissection, accomplished by infiltrating the subder­
mal plane with an anesthetic solution of lidocaine con­
taining epinephrine. Mobilization is continued until the
caudal border of the flap can be easily positioned without
tension 1- to 2-mm below the caudal margin of the lining
defect. To accomplish this, it is occasionally necessary to
extend the intercartilaginous incision inferomedially
from the anterior septal angle toward the membranous
septum.
The bipedicle vestibular skin advancement flap
consists only of skin. The overlying alar cartilage and
FIGURE 18-4  ■  A, Bipedicle vestibular skin advancement flap created by making an intercartilaginous incision between upper and
lower lateral cartilages. B, Flap mobilized sufficiently to allow caudal border to reach nostril margin. Thin full-thickness skin graft
used to repair flap donor site. C, Auricular cartilage graft provides framework for nostril margin. Lining flap secured to cartilage
graft with mattress sutures. (From Baker SR: Internal lining. In Baker SR, editor: Principles of nasal reconstruction, ed 2, New York, Springer,
2011.)
A
B
Skin graft
Auricular
cartilage
graft
C

420
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
the entire interior of the ala and nasal dome. Construc­
tion of the pedicle of the flap in this manner requires that
the flap span the distance from the caudal septum to the
lateral aspect of the lining defect. This means that the
flap will, in part or completely, obstruct the nasal passage
until it is detached from the septum.
In general, the septal mucoperichondrial hinge flap
should be designed as large as possible. Large flaps mea­
suring 4.0 to 4.5 cm in length and 2.5 to 3.0 cm in width
can provide sufficient mucoperichondrium to line the
entire lower nasal vault and limited portions of the caudal
aspect of the middle vault. A solution of lidocaine con­
taining epinephrine is infiltrated in the subperichondrial
plane along the entire length of the septum. Two hori­
zontal incisions extending from anterior to posterior are
made with a scalpel on an extended handle (Fig. 18-5).
The dorsal incision begins 0.75 cm posterior to the ante­
rior septal angle and extends along a line 0.5 to 1.0 cm
below the roof of the middle vault. It should extend 1 to
The number of sutures is limited to minimize risk of
vascular impairment of the flap. The donor site of the
flap is repaired with a thin full-thickness skin graft. If an
interpolated cheek flap is used for covering, the standing
cutaneous deformity that forms along the inferior aspect
of the medial cheek during primary closure of the cheek
donor site becomes the source of the skin graft.
Ipsilateral Septal Mucoperichondrial
Hinge Flap
Bipedicle vestibular skin advancement flaps are insuffi­
cient to line full-thickness defects of the unilateral tip or
ala that measure more than 1.5 cm in vertical height.
There is insufficient skin between the defect margin and
the intercartilaginous incision required to construct the
flap. In these circumstances, an ipsilateral septal mucop­
erichondrial flap hinged on the caudal border of the car­
tilaginous septum can provide adequate mucosa to reline
FIGURE 18-5  ■  A, Unipedicle septal mucoperichondrial hinge flap developed by incising through mucosa and perichondrium along
floor of nose and 1.5 cm below and parallel to cartilaginous dorsum. Incisions extend posteriorly beyond septal bony cartilaginous
junction. B, Flap dissected from superior to inferior and anterior to posterior. Anterior dissection remains 1 cm posterior to caudal
border of septum and 1.5 cm posterior to nasal spine. Flap based on intact mucoperichondrium of caudal septum and septal branch
of superior labial artery. C, Hinged on caudal septum, flap is reflected laterally to line lower nasal vault. D, Cartilage graft provides
nasal framework. Lining flap secured to framework with mattress sutures. (From Baker SR: Internal lining. In Baker SR, editor: Principles
of nasal reconstruction, ed 2, New York, Springer, 2011.)
A
B
C
D

18  RECONSTRUCTION OF THE NOSE
421
2 cm posterior to the bone-cartilage junction of the
septum. The inferior incision starts 1.0 cm posterior to
the anterior nasal spine and usually extends along the
junction of the nasal crest and the floor of the nose. The
incision should extend as far posteriorly as the dorsal
incision. A posterior vertical incision is then made
between the ends of the dorsal and inferior septal inci­
sions. This is accomplished with a right-angled scalpel.
A No. 66 Beaver eye blade is useful for this purpose.
The septal mucoperichondrial flap is dissected in the
subperichondrial plane from above downward toward the
floor of the nose and from anterior to posterior. The flap
is carefully delivered out of the nasal passage, exposing
septal cartilage and bone. A framework of cartilage grafts
is always required in instances in which an ipsilateral
septal mucoperichondrial hinge flap is used. The exposed
cartilage, and sometimes bone, is usually removed to
serve as a graft. For full-thickness alar defects, an auricu­
lar cartilage framework is occasionally preferred; in this
case, the septal cartilage and bone may remain in situ.
The exposed cartilage and bone eventually become
covered by a thin epithelium from healing by secondary
intention. When large or multiple grafts are required to
provide a framework for both the lower and middle
vaults, the septal cartilage should be harvested in conti­
nuity with portions of the bony septum. This is accom­
plished by use of a cartilage knife to make an anterior
vertical incision through the caudal septal cartilage, pre­
serving 1.0 to 1.5 cm of cartilage to serve as caudal
support to the nose. Contralateral mucoperichondrium
and mucoperiosteum are elevated away from the exposed
septal cartilage and bone through this incision. The infe­
rior border of the cartilaginous septum is then freed from
the nasal crest. An incision is made through the cartilage
superiorly, paralleling the dorsal mucosal incision made
previously to develop the hinge flap. Of the cartilage, 1.0
to 1.5 cm is left in situ above the incision to maintain a
dorsal septal strut providing support to the nasal bridge.
Angled turbinectomy scissors are used to make a hori­
zontal cut through the bony septum dorsally. Inferiorly,
portions of the vomer may be included in the specimen
by using a 4-mm-wide osteotome to cut through the
inferior border of the bony septum. The posterior ends
of the dorsal and inferior cuts through the bony septum
are connected by making a vertical cut through the bone
with a 2-mm-wide osteotome. Multiple perforations are
made through the bony septum with the osteotome until
the entire specimen can be gently rocked free.
When large grafts are not required, the exposed septal
cartilage is separated at the bone-cartilage junction and
removed for grafts. The exposed bone that has been
stripped of its mucoperiosteum may be removed piece­
meal or may be left to heal by secondary intention. If
septal cartilage is removed, the intact contralateral muco­
perichondrium is left undisturbed. The raw surface of the
mucoperichondrium will become covered with a thin epi­
thelium through healing by secondary intention.
The dissected mucoperichondrial flap is turned later­
ally as a hinge flap, with the mucosal surface facing
toward the nasal passage. Most defects requiring an ipsi­
lateral septal mucoperichondrial hinge flap extend
through the nostril margin. The distal corners of the
rectangular flap are usually sutured to the remaining
nostril margins; however, this may not always be the
preferred orientation of the flap. Flap positioning must
be adjusted to provide the maximum mucosal surface area
to the region that requires the most lining. The margins
of the hinge flap are then sutured to the margins of the
nasal mucosal defect.
The septal mucoperichondrial hinge flap is thin and
flexible and must be supported by a framework of septal
and auricular cartilage grafts carefully crafted to replicate
the contour of the missing region of the nose. Similar to
the bipedicle vestibular skin advancement flap, the ipsi­
lateral mucoperichondrial hinge flap is suspended to
overlying cartilage grafts with 5-0 polydioxanone sutures
that pass from the external surface of the grafts through
the cartilage and flap and back again. The number of
sutures is limited to those necessary to restore the desired
internal contour of the lower vault. It is important to
protect the cartilage grafts from exposure to the nasal
passage by providing complete internal coverage of the
grafts. This prevents contamination of the grafts with
nasal secretions and ensures a source of revascularization
of the undersurface of the grafts. Sealing off of the grafts
from the nasal passage is achieved by placing a few sutures
between the exposed submucosal surface of the hinge flap
and the cephalic border of the lining defect. Only two or
three sutures are necessary; they are tied in a fashion to
lightly approximate the submucosal surface of the flap
against the upper margin of the lining defect.
Bilateral Caudally Based Septal
Mucoperichondrial Hinge Flaps
A septal mucoperichondrial hinge flap based on the
caudal septum may be developed bilaterally (Fig. 18-6).
Concurrent bilateral flaps preclude the use of a dorsally
based septal mucoperichondrial hinge flap for repair of
more cephalically located lining deficits. Bilateral flaps
are indicated when a full-thickness defect of the entire
nasal tip is present but with an intact columella. In this
situation, each flap provides lining for the ipsilateral
hemi-tip and any portions of the adjacent ala that may be
absent. The flaps are designed, incised, and dissected in
a fashion identical to the methods for a unilateral flap.
The exposed septal cartilage is removed, leaving a per­
manent septal perforation as bilateral resurfacing of the
cartilage by secondary intention healing is unlikely. A
1.5-cm-wide dorsal and caudal strut of septal cartilage is
maintained for proper support of the nasal bridge. Each
flap is turned laterally and anteriorly in a hinged fashion
with the raw surface of the mucoperichondrium turned
outward. The flaps are sutured to their respective lining
defects and suspended to a framework of cartilage grafts
used to restore the structure and topography of the nasal
tip and any portions of the alae that may be missing.
Contralateral Dorsal Septal
Mucoperichondrial Hinge Flap
A mucoperichondrium hinge flap harvested from the side
opposite the nasal defect and based on the nasal dorsum
may be turned laterally to resurface the roof and lateral

422
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
adequate dorsal support for the nasal bridge. The flap is
reflected laterally across the midline toward the side of
the lining defect while maintaining its attachment to the
contralateral nasal dorsum. This maneuver turns the raw
undersurface of the mucoperichondrium outward, away
from the nasal passage. This flap is most commonly com­
bined with an ipsilateral mucoperichondrial flap hinged
on the caudal septum. The dorsally based flap passes
through the large septal perforation necessitated by the
use of the two flaps. The caudal border of the dorsally
based flap is sutured to the undersurface of the hinge
ipsilateral flap (see Fig. 18-7C). This maneuver seals off
the nasal passage from the exterior portion of the nasal
defect. A continuous carpet of mucoperichondrium can
then be used to nourish an overlying cartilage framework.
The flaps are suspended to the framework with mattress
sutures so there is intimate contact between the muco­
perichondrium and the entire undersurface of the carti­
lage grafts used for framework.
wall of the middle vault of the nose (Fig. 18-7).8 The flap
may be designed to include all of the mucosa covering
the cartilaginous septum, except for the mandatory main­
tenance of the caudal and dorsal strut of the septum.
Similar to the mucoperichondrial flap hinged on the
caudal septum, the elevation is facilitated by hydrodissec­
tion with a solution of local anesthetic injected beneath
the perichondrium. Anterior and posterior vertical inci­
sions are made with a right-angled scalpel. Incisions
extend from the floor of the nose to within 1 cm of the
nasal dorsum. The incisions are separated by the distance
appropriate for the desired width of the flap. The muco­
perichondrium is dissected with a Freer elevator as a
bipedicle flap attached to the dorsum above and the
floor of the nose below. Once the mucoperichondrium
has been completely freed from the septal cartilage,
it is released from the floor with a scalpel blade attached
to an extended handle. The exposed septal cartilage
is removed for grafting purposes (Fig. 18-8), leaving
FIGURE 18-6  ■  Bilateral caudally based septal mucoperichondrial hinge flaps. Flaps used to line bilateral full-thickness nasal tip defects
with intact columella. (From Baker SR: Intranasal flaps. In Baker SR, editor: Principles of nasal reconstruction, ed 2, New York, Springer,
2011.)

18  RECONSTRUCTION OF THE NOSE
423
the cartilage necessary for the framework of the colu­
mella and the concomitant lining to resurface the area of
the membranous septum and nasal domes (Fig. 18-9).
The flap is designed with the maximum width possible
while still preserving an adequate dorsal septal strut. The
flap is extended the entire length of the cartilaginous
septum and usually includes portions of the bony septum.
Typically, the flap is 3 cm wide and 5 cm long. Bilateral
mucoperichondrial flaps are created with a periosteal
elevator along the anterior floor of the nose adjacent to
the nasal spine. Access to this dissection is through the
anteroinferior margin of the defect near the nasal spine.
The dissection is extended superiorly over the lateral
aspect of the nasal crest until the septal cartilage is
encountered.
A 4-mm-wide osteotome is used to excise a 2-cm-long
segment of anterior nasal crest at the pivotal point of the
flap while preserving the anterior septal spine. A No. 11
scalpel blade is used to make a full-thickness incision
Septal Composite Chondromucosal Pivotal
Flap for the Tip and Columella
The septal composite chondromucosal pivotal flap is
indicated for large full-thickness defects of the central
nose, including combined tip and columella defects or the
nasal dorsum along with portions of the sidewall. For
lower vault defects, the composite flap is indicated only
when there is a full-thickness loss of the nasal tip and
adjacent columella. In instances of isolated full-thickness
tip defects with an intact columella, bilateral septal muco­
perichondrial flaps hinged on the caudal septum will
suffice for lining of the tip and any missing alae. Similarly,
large (greater than 75%) isolated full-thickness losses of
the columella are best reconstructed with an interpolated
cheek or paramedian forehead flap and do not require a
lining flap.
When the columella and nasal tip are both missing, a
septal composite chondromucosal pivotal flap provides
FIGURE 18-7  ■  A, Broken line indicates incision for ipsilateral septal mucoperichondrial flap. B, Flap reflected outward and exposed
septal cartilage removed. Broken and solid lines indicate incisions used to create contralateral dorsal septal mucoperichondrial hinge
flap. C, Dorsally based flap reflected laterally and sutured to borders of middle vault lining defect. Caudal border of flap sutured to
raw surface of ipsilateral flap to seal nasal passage from exterior. D, Caudally based hinge flap provides lining for lower nasal vault;
contralateral dorsally based hinge flap provides lining for middle and upper nasal vaults. E, Septal cartilage (blue) provides frame­
work for middle nasal vault; auricular cartilage (yellow) provides framework for lower nasal vault. Cartilage grafts scored to create
desired convex contour. Lining flaps attached to framework with mattress sutures. F, Nasal framework covered by paramedian
forehead flap. (From Baker SR: Internal lining. In Baker SR, editor: Principles of nasal reconstruction, ed 2, New York, Springer, 2011.)
Septal cartilage
Auricular cartilage
A
D
E
F
B
C

424
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
A
B
C
D
E
F
FIGURE 18-8  ■  A, Outline of ipsilateral mucoperichondrial hinge flap. Dorsal incision is parallel and 1 cm below attachment of upper
lateral cartilage to nasal septum. Inferior incision extends along junction of nasal crest with cartilaginous septum. B, Flap is elevated
in subperichondrial plane from anterior to posterior. C, Mucoperichondrium based on caudal septum is reflected laterally as hinge
flap. D, Exposed septal cartilage is freed from contralateral mucoperichondrium. L-shaped strip of septal cartilage 1 to 1.5 cm wide
is preserved dorsally and caudally to support middle and lower nasal vaults. E, Septal cartilage removed for grafting purposes.
Contralateral mucoperichondrium remains intact. Exposed bony septum may be removed or left in place. F, Contralateral dorsal
septal mucoperichondrial hinge flap outlined. The majority of contralateral mucoperichondrium is incorporated in flap. Flap is
created by two vertical and one inferior horizontally oriented incisions.

G
H
I
G, Flap incised and reflected laterally. H, Flaps sutured in position. Caudal edge of contralateral flap is tacked
to exposed raw submucosal surface of ipsilateral flap to seal off nasal passage from exterior. I, Ipsilateral flap is reflected laterally
to line lower nasal vault. Suture suspension of flap to overlying cartilaginous framework (not yet in place) restores arc of nasal
vestibule. (From Baker SR: Intranasal flaps. In Baker SR, editor: Principles of nasal reconstruction, ed 2, New York, Springer, 2011.)
FIGURE 18-8, cont’d  ■
FIGURE 18-9  ■  A, Bold broken line indicates full-thickness incision through septal cartilage, bone, and bilateral mucosa to create
composite septal chondromucosal pivotal flap. Faint broken line indicates incision made only through septal cartilage, preserving
overlying mucoperichondrium. Wedge of cartilage removed to enable flap to pivot anterocaudally. B, Cephalic aspect of pivotal flap
locked into place by abutting it against remaining cartilaginous dorsum. Bilateral mucoperichondrial flaps reflected laterally to
provide lining for nasal tip. C, Excess septal cartilage trimmed. Reflected mucoperichondrial flaps sutured to borders of lining defect.
D, Auricular cartilage graft (yellow) provides bilateral framework for nasal tip, replacing missing lateral crura. Septal cartilage (blue)
of composite flap serves as medial crura for reconstruction. Mucoperichondrial flaps attached to framework with mattress sutures.
(From Baker SR: Internal lining. In Baker SR, editor: Principles of nasal reconstruction, ed 2, New York, Springer, 2011.)
A
C
B
D
Full thickness
septal incisions
Wedge of
cartilage removed
Incision only through
septal cartilage
Septal composite
pivotal flap
Auricular cartilage
Septal cartilage

426
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
A framework of cartilage grafts is created from septal and
auricular cartilage to replace the missing portions of the
dome complex and lateral crura. The cartilage remaining
within the composite flap serves as the medial crura for
the construction and provides support to the columella.
It also serves as the foundation for the framework grafts
used for the nasal domes. These grafts are sutured directly
to the cartilage of the composite flap and are then scored
and bent in a fashion to restore the contour of the domes.
The mucoperichondrial flaps reflected laterally from the
composite chondromucosal flap are approximated to the
overlying framework grafts with sutures placed through
the framework cartilage and underlying flaps. Some of
the cartilage of the caudal aspect of the composite flap
may require trimming if it causes excessive caudal posi­
tioning of the reconstructed columella.
Septal Composite Chondromucosal
Pivotal Flap for Dorsum
There are occasions when a patient presents with an
intact nasal tip but has a full-thickness dorsal defect
involving loss of cartilaginous dorsum and nasal bones.
In these circumstances, the remaining septum may be
used as a composite chondromucosal pivotal flap to
provide a mucosal lining and structural support for the
roof of the middle and upper nasal vaults (Fig. 18-10).
The anterior septal angle is usually missing along with
the upper lateral cartilages, and the composite flap is used
to resurface the interior of the entire dorsal defect. The
flap is harvested in a manner similar to that described for
the pivotal flap used to reconstruct full-thickness defects
of the tip and columella. The flap pivots only 45°, com­
pared with 90° for repair of the tip and columella, so it
is not necessary to remove the anterior nasal crest bone.
Working through an endonasal approach as well as
through the dorsal defect, a full-thickness horizontal
incision is made through the septum along the length of
the nasal crest. The anterior extent of this incision
remains 1.5 cm posterior to the anterior nasal spine. The
length of the incision depends on the defect but usually
through the cartilaginous septum parallel to and 1.0 cm
below the attachments of the upper lateral cartilages to
the septum. The incision extends in an anterior direction
from the bony perpendicular plate through the exposed
margin of the caudal septum. A similar full-thickness
incision is made with the same blade along the interface
of the cartilaginous septum and the nasal crest, extending
anteriorly from the vomer until it is juxtaposed to
the previously resected nasal crest. The incision should
remain 1.5 cm posterior to the anterior nasal spine to
ensure a sufficient vascular pedicle. The pedicle is repre­
sented by bilateral mucoperichondrial flaps that are in
continuity with the floor of the nose anteriorly and nour­
ished by septal branches of the superior labial arteries.1
A posterior vertical incision is then made to connect the
two previously performed parallel horizontal incisions. If
the flap extends only to the bone-cartilage junction, the
incision is made with a right-angled scalpel; however, it
is usually necessary to include bony septum in the flap to
achieve adequate flap length. In these instances, the hori­
zontal incisions are extended posteriorly full thickness
through the bony septum and the covering mucosa on
either side with heavy-duty angled turbinectomy or
bone-cutting scissors. It is important to ensure that the
superior horizontal incision of the bony septum is com­
pleted before an osteotome is used to make the vertical
incision through the bony septum so that the force of the
osteotome is not transmitted to the region of the cribri­
form plate.
Once the septal incisions are completed, the compos­
ite flap is pivoted 90° on its base in an anterocaudal
direction until the inferior border of the flap locks in
place, bracing it against the remaining dorsal septal strut
(see Fig. 18-9).9 After the flap is positioned, bilateral
septal mucoperichondrial hinge flaps are dissected from
the distal portion of the flap’s bone and cartilage. The
flaps are reflected laterally to provide lining to the nasal
domes. Denuded cartilage and bone extending beyond
the planned dorsal line are resected and used for frame­
work grafts. The borders of the reflected mucoperichon­
drial flaps are sutured to the margins of the lining defect.
FIGURE 18-10  ■  A, Broken line indicates full-thickness incision through septal cartilage, bone, and bilateral mucosa to create composite
septal chondromucosal pivotal flap. B, Cephalic aspect of pivoted flap locked into place by abutting it against remaining nasal bony
septum. Bilateral mucoperichondrial flaps reflected laterally to provide lining to nasal passage. C, Excess septal cartilage and bone
trimmed and mucoperichondrial flaps sutured to borders of lining defect. Figure-of-eight suture fixes composite flap to remaining
nasal bony septum. (From Baker SR: Internal lining. In Baker SR, editor: Principles of nasal reconstruction, ed 2, New York, Springer, 2011.)
A
B
w
w
z
z
y
y
x
x
C

18  RECONSTRUCTION OF THE NOSE
427
the superior labial artery. In these circumstances, the flap
is based on the mucoperiosteum of the anterior floor of
the nose, and delay of the flap is necessary. Three stages
are used to line the nose.
Stage one consists of making the previously described
inferior horizontal incision along the floor of the nose
and vertical incision through the mucosa on either side
of the septum but not through the bone and cartilage.
Stage two is completed 3 weeks later by making incisions
through the cartilage and bone of the septum, following
the previous incision lines made in the covering mucosa.
The composite flap is delivered from the nasal passage
and is pivoted 90° to provide the maximum amount of
mucosa for construction of the lining of the caudal
portion of the nose. If the cephalic portion of the dorsum
is missing, there will not be a buttress on which to stabi­
lize the pivoted flap. In this case, nasal packing is used to
stabilize the flap. Packing is left in place for 5 days. The
flap is left protruding from the nasal passage for 4 to 6
weeks before proceeding with reconstruction of the nasal
lining. Stage three consists of creating bilateral mucop­
erichondrial flaps based on the anteroinferior border of
the mobilized composite flap. The flaps are reflected lat­
erally to line the roof and sidewalls of the caudal nose. If
extends 2 to 3 cm posteriorly through the bony septum.
This is usually necessary to ensure sufficient length to
enable the flap to engage the frontal bone or remaining
nasal bones once it is pivoted into position. A vertical
incision is extended from the posterior end of the hori­
zontal incision along the floor of the nose. This septal
incision extends upward to join the most cephalic aspect
of the bony or cartilaginous septum exposed by the
defect. The flap is delivered from the nasal passage by
manually pivoting the flap 45° on its pedicle. It may be
necessary to remove cartilage in the area of the posterior
septal angle to pivot the flap. This should be performed
so that the adjacent mucoperichondrium is not damaged;
this tissue represents the pedicle for the flap.
Septal Composite Chondromucosal Pivotal
Flap for the Tip, Columella, and Dorsum
Total and near-total nasal reconstruction may use the
septum for internal lining if sufficient septum remains.
This requires incorporation of the entire remaining nasal
septum in the composite flap (Fig. 18-11). These cases
are frequently associated with resection of the caudal
cartilaginous septum and loss of the septal branches of
FIGURE 18-11  ■  A, Bold broken line indicates full-thickness incision through septal cartilage, bone, and bilateral mucosa. Solid bold
line indicates incision only through septal cartilage, preserving mucoperichondrium. Wedge of cartilage removed to enable flap to
pivot anterocaudally. B, Cephalic aspect of pivoted flap locked into place by abutting it against nasal process of frontal bone. Bilateral
mucoperichondrial flaps reflected laterally to provide lining to nasal passages. C, Excess septal cartilage and bone trimmed and
mucoperichondrial flaps sutured to borders of lining defect. Figure-of-eight suture stabilizes composite flap to nasal process. Septal
cartilage (blue) and auricular cartilage (yellow) provide nasal framework. Cartilage grafts scored to create desired convex contour.
Mucoperichondrial flaps attached to framework with mattress sutures. D, Nasal framework covered by paramedian forehead flap.
(From Baker SR: Internal lining. In Baker SR, editor: Principles of nasal reconstruction, ed 2, New York, Springer, 2011.)
A
x
w
y
z
x
w
y
z
B
C
D

428
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
containing a concentration of epinephrine of 1 : 100,000
is infiltrated along the turbinate, floor of the nose, and
middle or inferior meatus, depending on which turbinate
is used. The turbinate is medialized with a blunt elevator
or the handle of a scalpel to open the meatus below the
turbinate. A Cottle elevator or a 2-mm osteotome is
placed in the meatus below the turbinate and pushed
superiorly to perforate the bony attachment to the lateral
nasal wall. Multiple perforations of the bone are made
along the length of the turbinate, starting 1 cm posterior
to the anterior end of the turbinate. The cutting instru­
ment is maintained in a vertical plane against the lateral
nasal wall to maximize the amount of tissue obtained
without penetrating the paranasal sinuses. Pedicled ante­
riorly, the posterior aspect of the mobilized turbinate is
pivoted toward the nasal defect with Takahashi forceps.
The bone of the delivered turbinate is removed, leaving
a mucosal flap that is transferred to the recipient site and
sutured in position. If the location of the lining defect is
the nasal tip, the pedicle of the flap will, by necessity, span
the nasal passage and partially obstruct the airway. In this
case, detachment of the pedicle is accomplished under
local anesthesia 3 weeks later.
the flaps are lacking sufficient tissue to line the cephalic
portions of the nasal passage, local turn-in flaps or a
paramedian forehead flap is used as lining for this portion
of the nose. The reflected mucoperichondrial flaps are
supported by an overlying framework of cartilage and
bone that is covered by a paramedian forehead flap.
Turbinate Mucoperiosteal Flap
The middle and inferior turbinates may be used to line
limited mucosal defects of the nose.10 These turbinates
are richly supplied by a vascular network arising from a
lateral descending branch of the sphenopalatine artery.
The main supply to the inferior turbinate from this artery
enters 1.0 to 1.5 cm from its posterior border and passes
forward, giving off an anastomotic network of vessels.
The artery also has anastomotic connections with the
anterior blood supply of the turbinate. The anterior
blood supply originates from the angular artery and is
sufficient to allow the entire turbinate to be pedicled on
this source.11,12
Middle and inferior turbinate flaps are harvested by a
similar technique (Fig. 18-12). A local anesthetic solution
FIGURE 18-12  ■  A, Inferior turbinate released from bony attachment to lateral nasal wall (dotted line). B, Mucoperiosteum dissected
from underlying concha bone and unfurled. Bone removed. C, Pedicled anteriorly, inferior turbinate mucoperiosteal flap is usually
sufficient to line entire ala. (From Baker SR: Intranasal flaps. In Baker SR, editor: Principles of nasal reconstruction, ed 2, New York, Springer,
2011.)
A
C
B

18  RECONSTRUCTION OF THE NOSE
429
Structural support for the columella can also be pro­
vided by conchal cartilage grafts. A graft is placed in such
a way as to span the gap in the medial crus or to extend
all the way to the nasal spine if the entire medial crus is
absent. Septal cartilage grafts are effective for this purpose
as well but must be thinned, scored, and bent so they
replicate the diverging angle that naturally occurs at the
junction of the medial and intermediate crura.
An alar batten of septal or conchal cartilage 5 mm
wide is used for the framework of the ala and nasal
facet. The natural curvature of the conchal cartilage
makes this material preferable to septal cartilage when it
is available (Fig. 18-14). When a portion or all of the
lateral crus is missing in addition to the ala, a separate
conchal cartilage graft may be used to replace the
missing crus. Alternatively, a single piece of ear cartilage
may be used for both. In such circumstances, the graft is
designed wider (0.75 to 1.0 cm) to replace the lateral
crus and to provide support to the ala concomitantly.
The graft is placed along the proposed margin of the
missing nostril from the alar base to the nostril apex. It
is inserted into a deep tissue pocket in the alar-facial
sulcus and is attached medially to the framework of the
dome (Fig. 18-15). The tissue pocket serves to stabilize
the graft laterally. Similar to the grafts used to replace
missing alar cartilage, grafts must be thinned, scored,
and bent to replicate the bulging contour of the ala. If
the nasal defect extends into the soft tissue facet, the
cartilage graft is extended beneath the diverging angles
of the intermediate and lateral crura to span any gap
present. The graft fixes the reconstructed nostril rim in
position, preventing upward migration and notching of
the rim.
In summary, the surgeon must determine what part of
the nasal framework is missing and replace it completely.
Each element replaced must be carefully shaped, thinned,
scored, bent, and fixed with regard to nasal projection,
contour, nostril rim position, and symmetry so that it
exactly replicates the contralateral counterpart or the
ideal if both components of the framework are missing.
The better the surgeon is able to achieve this goal, the
better the aesthetic and functional results.
FRAMEWORK
The dorsum of the nose is supported by the nasal bones
and cartilaginous septum; the sidewalls, by the frontal
processes of the maxillae and upper lateral cartilages; the
tip, by the intermediate and lateral crura of the alar car­
tilages; the columella, by the medial crura; and the alae
and nasal facets, by stiff fibrofatty connective tissue. If it
is missing, the nasal framework of each unit is completely
replaced. Cartilage grafts may be used to replace the
missing framework of the dorsum, tip, and sidewalls. In
addition, a strip of cartilage is placed along the recon­
structed nostril margin whenever the connective tissue
framework is missing. In instances of alar reconstruction,
this usually means positioning a strip of cartilage to span
the distance from the alar base to the region of the facet,
even though these areas do not normally contain carti­
lage. This is required to support the nostril rim and to
prevent migration upward of the nostril margin during
wound healing.
The function of the framework is to provide contour
and to maintain a patent airway. Framework grafts are
usually placed at the time of initial reconstruction and
should consist of grafts that as nearly as possible replicate
the exact size, shape, and contour of the missing frame­
work. When it is covered by a thin, conforming cutane­
ous flap, the contour of the framework is distinctively
manifested and produces a normal-appearing restoration
of the missing part. Framework grafts fix in place the soft
tissues used in nasal repair by virtue of providing a skel­
etal support for both lining and cover.
Bone and cartilage are the tissue grafting materials
available to the surgeon for replacement of the frame­
work of the nose. The framework of the nasal dorsum
may be replaced with bone or cartilage. Cranial bone
grafts are the preferred material for more cephalic skel­
etal defects and are anchored to the frontal bone with
miniplates. Limited caudal dorsal skeletal defects may be
replaced with septal or auricular cartilage when it is avail­
able. The dorsal framework prevents cephalic contrac­
tion and subsequent shortening of the nose. It also
provides shape and projection to the bridge. The frame­
work of the sidewall may be replaced with septal bone
and cartilage or cranial bone contoured into a trapezoid
shape and fixed to the dorsum and maxilla. It supports
the middle vault and prevents collapse. It also serves
as a foundation for attachment of the lower framework
of the nose, specifically the alar cartilages or their
replacements.
The tip is shaped by the alar cartilages, and the pre­
ferred replacement framework is conchal cartilage grafts.
By coincidence, when it is turned upside down, the con­
tralateral conchal cymba often closely resembles the
shape of the dome cartilage (intermediate crus), and the
conchal cavum resembles the shape of the lateral crus
(Fig. 18-13). A graft 5 to 8 mm wide from the auricle can
be used to replace the entire lower lateral cartilage. Such
grafts may be used bilaterally or unilaterally as required
and are fixed to any residual stumps of the medial and
lateral crura. They support the dome and re-create the
contour of the nasal tip.
FIGURE 18-13  ■  When it is turned upside down, contralateral
conchal cymba (above) resembles shape and contour of lower
lateral cartilage (below).

430
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 18-15  ■  Single cartilage graft replaces missing lateral
crus of alar cartilage and extends to caudal margin of nostril to
support alar region. (From Naficy S: Cartilage grafts. In Baker SR,
editor: Principles of nasal reconstruction, ed 2, New York, Springer,
2011.)
FIGURE 18-14  ■  Auricular cartilage grafts
used to replace missing segments of alar
cartilage and to support ala. (From Naficy S:
Structural support. In Baker SR, editor: Princi­
ples of nasal reconstruction, ed 2, New York,
Springer, 2011.)
COVERING FLAPS
Nasal Cutaneous Flaps
Primary wound closure is possible for smaller skin defects
of the nose, especially in the elderly patient, in whom
nasal skin tends to be redundant, or when defects are very
small relative to the size of the nose (Fig. 18-16). Defects
that are 1.0 cm or smaller and located on the dorsum or
sidewall are repaired most easily. This is accomplished by
advancement of opposing wound margins after wide
undermining of the skin adjacent to the defect. Standing
cutaneous deformities form at the margins of the repair
and usually require excision (Fig. 18-17). Primary wound
closure of defects of the tip and supratip area frequently
distorts the free margins of the nostril. Fortunately, alar
cartilages typically have sufficient intrinsic strength to
counteract this distortion; over time, the nostril margin
usually returns to its natural position.
When primary wound closure is not possible, cutane­
ous flaps harvested from the nasal skin may be an alterna­
tive for repair of centrally located nasal skin defects that
measure up to 2.5 cm in greatest dimension. Nasal cuta­
neous flaps are particularly useful for elderly patients
because their skin is lax and mobile. When they are
designed properly, flaps harvested from nasal skin have
the advantage of color, texture, and thickness similar to
those of the missing skin of the defect. Nasal cutaneous
flaps are not sufficient to resurface an entire aesthetic unit
of the nose, and the scars resulting from flap transfer do
not always fall in the borders between aesthetic units.

18  RECONSTRUCTION OF THE NOSE
431
FIGURE 18-16  ■  A, A 1.2 × 1.1-cm skin defect of nasal tip. Primary wound closure planned. Anticipated standing cutaneous deformities
marked by horizontal lines. B, C, Deformities excised and wound closed. D, Postoperative view at 7 months. Scar dermabraded 3
months postoperatively.
A
B
C
D
FIGURE 18-17  ■  A, A 1 × 0.8-cm skin defect of dorsum. Primary wound closure planned. Anticipated standing cutaneous deformities
marked. B, Deformities excised. Wound closed. C, Postoperative view at 9 months. Scar dermabraded.
A
B
C

432
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
thin skin zones of the nose (Fig. 18-18). Flaps confined
within thick skin zones work poorly unless the defect is
small (0.5 cm or smaller in maximum dimension). The
thicker skin of the caudal nose is stiff and inelastic; trans­
position flaps created from this skin produce large stand­
ing cutaneous deformities and excessive wound closure
tension. Transposition flaps are most useful for repair of
defects located on the cephalic nasal sidewall and dorsum
in the vicinity of the rhinion. In these areas, the mobility
of nasal skin allows ease of transposition and enables dis­
sipation of most of the standing cutaneous deformity that
However, the ultimate contour of the nasal repair is far
more important aesthetically than the location or number
of scars.
Transposition Flaps
Transposition flaps are pivotal flaps with a linear axis.
The base of the flap is positioned adjacent to the defect,
and the donor site is repaired primarily by advancement
of surrounding nasal skin. The use of transposition flaps
is restricted to repair of defects 1.0 cm or smaller in the
FIGURE 18-18  ■  A, A 1.2 × 1.2-cm skin defect of nasal sidewall. Transposition flap designed for repair. B, Flap transposed. C, D, Post­
operative view at 1 year. No revision surgery performed.
A
B
C
D

18  RECONSTRUCTION OF THE NOSE
433
V-to-Y Island Pedicle Advancement Flap
Small skin defects located in the region of the anterior
alar groove between the ala and tip may be effectively
repaired with a V-Y advancement flap transferred as a
cutaneous island and based on a subcutaneous tissue
pedicle consisting of nasalis muscle and subcutaneous fat.
It is useful for skin defects up to 1.5 cm in maximum
dimension located in the junctional zone between the
nasal tip and ala, including the nasal facet (Fig. 18-20).
A triangular flap, with its base making up the cephalic
border of the defect, is designed with the apex of the
flap positioned laterally. The inferior border of the flap
rests in the alar groove. The superior border extends
laterally from the defect to include skin of the nasal
sidewall and tapers to meet the inferior border in the
alar-facial sulcus. The flap is incised to the level of the
perichondrium of the lateral crus. The adjacent skin is
undermined widely over the nasal tip, dorsum, and side­
wall, extending inferiorly beneath the skin of the ala to
the level of the caudal border of the defect. Beginning
forms from transfer of the flap. Remaining deformities
may safely be removed without influencing the vascular­
ity of the flap, thus making the repair one stage (Fig.
18-19). Confining transposition flaps to thin skin zones
of the nose reduces contour irregularities by maintaining
similar tissue thickness of the flap and recipient site. In
contrast, transposition flaps transferred from thin to thick
skin zones inevitably result in a mismatch of tissue thick­
ness and create a permanent unnatural topography in the
region of reconstruction.
Bilateral transposition flaps are frequently useful for
repair of small nasal defects. The flaps are designed with
angulated rather than curved borders, thus giving a
“corner” to the flap. To facilitate this design, it may be
necessary to modify the configuration of the skin defect
from a more common round shape to one that has an
angulated configuration. The angulated borders of the
repair retard concentric scar formation and reduce the
problem of trap-door deformity commonly observed
with curvilinear scars. Wide undermining of adjacent
nasal skin is also helpful in preventing this problem.
FIGURE 18-19  ■  A, A 1.5 × 1.6-cm skin defect of nasal sidewall. Transposition flap designed for repair. Standing cutaneous deformity
(SCD) marked. Arrows indicate orientation of greatest wound closure tension. B, Flap transposed and wound closed. Bolster sutures
in place. C, Bolster dressing in place. D, Postoperative view at 2 years. Scar dermabraded.
A
SCD removed here
B
C
D

434
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 18-20  ■  A, A 0.8 × 0.7-cm skin defect of alar groove. V-Y island subcutaneous tissue pedicled advancement flap designed for
repair. B, Flap incised and advanced on nasalis muscle. C, Flap in place. D, Postoperative view at 4 months.
A
B
C
D

18  RECONSTRUCTION OF THE NOSE
435
that it may be advanced as far forward as the nostril
margin. The pedicle is bluntly freed from the upper and
lower lateral cartilages sufficiently to permit only the
exact degree of flap advancement necessary for wound
repair. The vascular supply to the flap is from the alar
branch of the angular artery. This branch is occasionally
observed during the dissection; it perforates the deep
tissues in the extreme lateral aspect of the alar groove.
The vessel is preserved whenever possible to provide
the flap with a more axial vascular supply. The flap is
at the cephalic border of the defect, fine scissors are
used to undermine beneath the cutaneous island, liber­
ating the distal third of the island from soft tissue
attachments. Next, the proximal (lateral) third of the
flap is dissected in the subcutaneous plane, freeing it
from surrounding tissue. The muscle and subcutaneous
fat underlying the central third of the flap are not dis­
turbed and represent the pedicle (Fig. 18-21). It is this
zone of tissue attachment, located in the central portion
of the alar groove, that provides mobility to the flap so
FIGURE 18-21  ■  A, A 1 × 1-cm skin defect of lateral tip and alar groove. V-Y island advancement flap incised. B, Muscle and subcu­
taneous fat underlying central third of flap provide vascular supply to flap. C, Flap in place. D, E, Preoperative and 6-month post­
operative views. No revision surgery performed.
A
B
C
D
E

436
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
secured at the recipient site first, and then the donor
site is closed, creating a Y configuration to the repair.
Dorsal Nasal Flaps
The dorsal nasal flap recruits redundant skin of the gla­
bella and is a pivotal flap that can be used to repair skin
defects of the nasal tip, dorsum, and sidewall. The dorsal
nasal flap enables the surgeon to repair relatively large
caudal and midnasal defects measuring 2.5 cm in diam­
eter or less with matching adjacent tissue. There is insuf­
ficient nasal skin to repair larger defects in this manner.
The flap is ideally suited for elderly patients for repair of
defects located centrally on the tip. By necessity, the flap
is large to maximize tissue movement and to decrease
wound closure tension at the donor site. Distortion of
the free margins of the nasal tip and alae is prevented by
the compensatory size of the flap, which incorporates the
majority of the remaining nasal skin. It is imperative to
assess skin laxity and to plan for some degree of secondary
movement at the free margins of the nasal alae and tip.
Skin laxity in the glabella and dorsal nasal regions is best
determined by the pinch test, which consists of grasping
the skin between the surgeon’s thumb and index finger
and determining the amount of redundancy.13 For success,
sufficient skin laxity is present when the surgeon can
gather 1 to 2 cm of skin on the nasal bridge and glabella.
Greater laxity is necessary as the size of the defect
increases.
A common disadvantage of the dorsal nasal flap is
cephalic displacement of the nostril margin and nasal tip.
In older patients with tip ptosis and a central tip skin
defect, slight elevation of the nasal tip is beneficial.
However, in younger patients, elevation of the tip may
result in an unacceptable appearance. Repair of lateral
nasal defects may result in permanent mild to extreme
elevation of the ala in patients with insufficient laxity of
the nasal and glabellar skin. In spite of aggressive thin­
ning of the flap in the area of the medial canthus, marked
discrepancy in thickness between flap and native medial
canthal skin is often a problem. This is the greatest dis­
advantage of this flap, which precludes its common use
by the author.
The author occasionally uses a modified design of the
dorsal nasal flap for midline skin defects of the cephalic
dorsum (see Chapter 7 for in-depth discussion). The
design is such that the lateral border of the flap remains
anterior to the thin skin of the medial canthal region to
avoid mismatch in skin thickness. I call this design a
dorsal heminasal flap. The design limits the arc of tissue
movement; therefore, the modified flap may be used only
for smaller (less than 2 cm) skin defects of the nasal
bridge that are cephalad to the nasal tip. The dorsal
heminasal flap usually requires a glabellar incision. The
lateral incision is along the junction of the nasal sidewall
and dorsum and therefore recruits skin only from the
nasal bridge and lower central forehead (Fig. 18-22).
Bilobe Flaps
The bilobe flap has a geometrically precise configuration;
design of the flap is discussed in detail in Chapter 10. The
ideal nasal defect for repair with a bilobe flap is a small
(less than 1.5 cm) defect at least 5 mm from the margin
of the nostril located on the tip or sidewall. The flap is
preferably based laterally and is designed so that the
standing cutaneous deformity resulting from pivoting of
the flap is removed parallel to or in the alar groove.
When it is designed as a laterally based flap, the base of
the standing cutaneous deformity develops at the lateral
border of the defect with its apex pointing laterally. The
base of the deformity is approximately one-half to two-
thirds the diameter of the defect. Each lobe is designed
with greater and lesser arcs that have the same center
point (Fig. 18-23). This point is placed in or parallel to
the alar groove at a distance from the lateral border of
the defect equal to the radius of the defect. By use of this
point, two arcs are created. The lesser arc bisects the
defect, passing through the center of the defect. The
greater arc is designed so it is tangent to the defect border
most peripheral to the center point of the arc. Both lobes
of the bilobe flap arise from the lesser arc. The height of
the first lobe extends from the lesser to the greater arc.
The height of the second lobe is twice the height of the
first lobe and is triangulated to facilitate closure of its
donor site. The width of the first lobe is designed equal
to the diameter of the defect, which prevents elevation of
the nostril free margin. The width of the second lobe may
be reduced to two-thirds the width of the first lobe. The
linear axes of each lobe are positioned at approximately
45° from each other with the primary lobe axis positioned
45° from the axis of the defect. The flap is elevated just
above the perichondrium and periosteum of the underly­
ing nasal framework. If the thickness of the primary lobe
is greater than the recipient area, the lobe may require
thinning even to the level of the dermis to match the
thickness of the skin at the recipient site. After incision
of the flap, wide peripheral undermining of essentially all
of the skin of the nose is important to reduce wound
closure tension, to facilitate flap transfer, and to minimize
trap-door deformity. The first lobe of the flap is trans­
posed into the defect and secured with sutures. Next, the
donor site of the second lobe is closed primarily. Last,
the second lobe is inset and trimmed appropriately to fit,
without redundancy, the donor defect of the first lobe.
The bilobe flap is most useful in patients with nasal
tip defects and having thin nasal skin. The flap is also
useful for repair of skin defects of the lateral tip or caudal
nasal sidewall (Figs. 18-24 and 18-25). In such cases, the
flap is constructed from the lax skin along the nasal side­
wall. The surgeon may estimate skin laxity by pinching
the lateral nasal skin between the thumb and index finger.
Patients with thick sebaceous skin have a higher risk of
flap necrosis and development of trap-door deformity.
Dermabrasion, 6 weeks after flap transfer, is recom­
mended for most patients reconstructed with a bilobe
flap.
Melolabial Interpolated Flap
Most nasal cutaneous malignant neoplasms occur on the
caudal third of the nose. Commonly, after micrographic
surgery, the surgeon is requested to reconstruct the ala.
Small skin defects of the tip, dorsum, or sidewall may be

18  RECONSTRUCTION OF THE NOSE
437
FIGURE 18-22  ■  A, A 1 × 1-cm skin graft on dorsum marked for excision. Dorsal heminasal flap designed for repair of wound after
excision. Anticipated standing cutaneous deformity from pivot of flap marked with vertical lines. B, Graft excised and flap dissected.
C, Flap in place. D, Postoperative view at 8 months. Flap dermabraded.
A
B
C
D

438
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 18-23  ■  A, A 1.4 × 1.2-cm skin defect of tip. Bilobe flap designed for repair. Anticipated standing cutaneous deformity marked
for excision in alar groove. Base of each lobe arises from lesser arc. Height of first lobe extends from lesser to greater arc. Height
of second lobe twice height of first lobe. B, Flap in place. C, D, Postoperative views at 6 months. No revision surgery performed.
C
D
A
Lesser arc
Greater arc
B

18  RECONSTRUCTION OF THE NOSE
439
A
SCD removed here
45 degree angles
B
FIGURE 18-24  ■  A, A 1.1 × 1.1-cm skin defect of lateral nasal tip. Linear axes of each lobe designed 45° from each other. This creates
45° skin triangles between lobes. Standing cutaneous deformity (SCD) marked. B, Flap in place.
Continued
left to heal by secondary intention. Although this may at
times create an unsightly scar, it rarely results in func­
tional impairment. In contrast, even very small defects
(1 cm) of the ala left to heal by secondary intention cause
notching of the nostril and may cause partial collapse of
the external nasal valve, especially on inspiration. For this
reason, essentially all cutaneous defects of the ala require
reconstruction. Most often it is necessary to use a melo­
labial interpolated flap as the covering flap for the ala.
The predominant reason to use this flap rather than a
transposition flap is that transposition flaps transferred
from the cheek to the nose deform the alar-facial sulcus
and lateral portion of the alar groove. A portion of the
flap by necessity must pass through the superior aspect
of the alar-facial sulcus, which represents an important
topographic junction between the facial aesthetic regions
of the nose, cheek, and upper lip. Whenever possible,
local flaps should be designed so they do not cross borders
that separate aesthetic regions. This is especially true if
the border has a concave topography like that of the alar-
facial sulcus.4 Too often, this sulcus has been violated by
transposition flaps harvested from the cheek to recon­
struct caudal lateral nasal defects. The flap passes through
the sulcus, obliterating the valley between the ala and
cheek. When this happens, it is extremely difficult to
restore the valley to a completely natural contour. For
this reason, an interpolated melolabial flap is recom­
mended for reconstruction of the ala. The pedicle of the
flap crosses over the alar-facial sulcus, avoiding the sulcus
altogether. The pedicle may consist of skin and subcuta­
neous fat or subcutaneous fat only and is detached from
the cheek 3 weeks after the initial transfer to the nose.
Although 3 weeks is a lengthy period for the patient to
endure the deformity caused by the flap, this interval
enables the surgeon to thin and sculpt the subcutaneous
tissues of the distal flap at the time of flap transfer and
the proximal portion of the flap at the time of pedicle
detachment and flap inset. On inset of the flap, the patient
is left with a completely natural alar-facial sulcus because
no incision or dissection has been performed in this
region.
The nasal-alar unit is highly contoured, has a free
margin, and functions as the external nasal valve. When
the ala is reconstructed, consistent restoration of function
requires a cartilage subsurface framework to resist the
forces of contraction, to provide a stable external valve,
and to serve as a scaffold for contour. The framework in
the form of a cartilage graft is used at the time of the
initial reconstructive procedure and requires vascularized
tissue superficial and deep to the graft, totally enveloping
the cartilage (Fig. 18-26). Adequate function of the nose
requires a thin internal layer most appropriately supplied
by vascularized mucosa. The external covering flap is
provided by an interpolated cheek or forehead flap.
The porous and sebaceous nature of medial cheek skin
closely resembles that of the caudal third of the nose, so
an interpolated cheek flap is generally the preferred cov­
ering flap for alar reconstruction. The flap is based supe­
riorly on the rich vascular supply in the region of the
alar-facial sulcus.14 In this location, perforating branches
from the angular artery penetrate the levator labii muscle.
Other perforating vessels on both borders of the midpor­
tion of the zygomatic major muscle assist in supplying
the cheek skin adjacent to the ala. The superiorly based
flap may be designed as a peninsular flap based on a
cutaneous pedicle or as an island based on a subcutaneous
tissue pedicle. In most circumstances, I prefer to design
the flap as a crescent-shaped island of skin based on a

440
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
E
F
C
D
C-F, Preoperative and 1-year postoperative views. No revision surgery performed.
FIGURE 18-24, cont’d  ■

18  RECONSTRUCTION OF THE NOSE
441
FIGURE 18-25  ■  A, A 1.1 × 1.1-cm skin defect of alar groove. Bilobe flap designed for repair. Auricular cartilage nostril rim graft in
place. B, Flap transposed. C, D, Postoperative views at 1 year. No revision surgery performed.
C
D
A
Auricular cartilage rim graft
B
subcutaneous tissue pedicle. The superior extent of the
island remains 5 mm below the alar-facial sulcus, preserv­
ing this important aesthetic area (see Fig. 18-26).4
An exact template of the alar unit is made from the
contralateral normal side with a malleable material such
as foil or a thin sheet of foam rubber (Fig. 18-27). The
template is reversed to design the interpolated cheek flap.
When the defect extends beyond the confines of the ala,
a template is designed slightly smaller than the defect to
accommodate the phenomenon of distraction of the
wound margins, which creates an open wound that
is larger than the surface area of the skin removed. If
excision of additional skin is indicated to resurface an
adjacent aesthetic unit, the template is fashioned before
the remaining skin is removed because of this same
phenomenon.
The fashioned template is placed on the melolabial
fold so that the center of the flap is positioned 1 cm
superior to the horizontal plane of the lateral oral com­
missure. The template is positioned over the melolabial
fold so that the medial border of the designed flap lies in
the melolabial crease. This arrangement ensures that the
flap is harvested from the cheek, not the lip, and that
donor site wound closure will lie within the melolabial
crease, providing maximum scar camouflage. The flap is
designed to pivot 90° toward the midline in a clockwise
direction when it is harvested from the left cheek and
counterclockwise when it is harvested from the right
cheek. Thus, the template is positioned to design the flap
with a specific orientation. As the flap is pivoted and
transferred to the recipient site, the in situ medial border
of the flap is sutured to the cephalic border of the defect.
This in turn causes the in situ inferior border of the flap
to join the anterior border of the defect. The lateral
border of the in situ flap becomes the inferior border of
the reconstructed ala (see Fig. 18-26).
A tracing is made around the template. A triangle of
skin is marked superior and inferior to the tracing to
fashion a crescent-shaped island of skin (see Fig. 18-27).
The two triangles extending from the template tracing
represent standing cutaneous deformities that will form
when the cheek wound is closed. The lower triangle of

442
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 18-26  ■  A, Bipedicle vestibular skin advancement flap used to line full-thickness alar or unilateral tip defects that have vertical
dimension of 1 cm or less. Flap created by extended intercartilaginous incision between lateral crus and caudal aspect of upper
lateral cartilage (broken line). B, Remaining vestibular skin mobilized caudally in form of bipedicle advancement flap. Flap donor
site repaired with thin full-thickness skin graft. C, Auricular cartilage graft provides framework for nostril margin. Graft secured to
vestibular skin flap with mattress sutures. Remaining skin of alar base discarded. Interpolated cheek flap designed (broken line).
D, Interpolated flap based on subcutaneous tissue pedicle turned toward midline as covering flap. Note orientation of flap relative
to design. Cheek donor site closed primarily after removal of standing cutaneous deformity inferiorly, which is used as source for
skin graft. (From Baker SR: Interpolated cheek flaps: reconstruction of the alar and columellar units. In Baker SR, editor: Principles of nasal
reconstruction, ed 2, New York, Springer, 2011.)
A
B
C
x
y
z
D
Skin graft
X
Y
Z

18  RECONSTRUCTION OF THE NOSE
443
A
B
C
D
E
F
G
FIGURE 18-27  ■  A, A 1.5 × 1-cm skin defect of ala. Remaining skin of aesthetic unit marked for excision. B, Auricular cartilage used
for framework of ala. C, Skin excised and cartilage graft sculpted and positioned along nostril margin. D, E, Foam rubber sheet used
to create template of defect and to design flap. F, Interpolated melolabial island flap designed as covering flap for ala. G, Flap transfer
to nose based on subcutaneous tissue pedicle.
Continued

444
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
H
I
H, I, Preoperative and 3-year postoperative views. Flap contouring procedure performed.
FIGURE 18-27, cont’d  ■
skin is excised at the time of flap transfer, and the upper
triangle is transferred with the skin of the flap and is
discarded at the time of pedicle detachment and inset of
the flap. The superior triangle of skin is minimized to
reduce loss of tissue from the superior melolabial fold
where the fold is well developed. Removal of skin from
the superior portion of the fold may result in asymmetry
of the medial cheeks.
The flap is incised, and the distal portion is elevated
in the subcutaneous plane. The distal third of the flap is
thinned, leaving 1 to 2-mm of subcutaneous fat attached
to the undersurface. As the dissection proceeds superi­
orly, the plane extends deeper to facilitate development
of the subcutaneous tissue pedicle (Figs. 18-28 and 18-
29). The pedicle of fat is freed from the surrounding
cheek fat by incising through the borders of the pedicle
perpendicular to the surface of the skin. The depth of the
incision is carried to the level of the superficial surface of
the zygomatic major and levator labii muscles. On reach­
ing the zygomatic major muscle, blunt dissection contin­
ues upward on the surface of the muscle, releasing the
attachments of the pedicle to deeper structures until the
flap can reach the recipient site without undue tension.
Dissection of the flap continues until it can be trans­
ferred to the nose without excessive tension on the
pedicle. The four corners of the flap are secured to the
nasal skin at the recipient site with 5-0 polypropylene
vertical mattress sutures. No subcutaneous sutures are
used. Additional vertical mattress sutures are placed
around the perimeter of the flap to secure the flap in
place. Precise skin edge approximation between the flap
and adjacent native skin is achieved with a running 5-0
fast-absorbing gut suture.
When the alar defect extends into the alar-facial sulcus
and medial cheek, a cutaneous cheek advancement flap is
necessary to repair the cheek component of the defect.
In this circumstance, the cheek advancement flap is dis­
sected first, exposing the underlying subcutaneous tissues
of the cheek. A cutaneous island transferred as a subcu­
taneous tissue pedicled interpolated flap is used as cover­
ing for the constructed ala. The island flap is dissected,
and the pedicle is delivered to the nose beneath the cheek
advancement flap (Fig. 18-30). The island flap does not
require inset; however, the pedicle usually causes exces­
sive fullness adjacent to the alar-facial sulcus. Thus, a
procedure to contour the region is often necessary and is
performed 2 to 3 months after flap transfer. On occasion,
a second contouring procedure may even be necessary
(Fig. 18-31).
For closure of the donor wound after transfer of an
interpolated cheek flap, the skin adjacent to the incision
is undermined peripherally for a distance of 2 cm in the
superficial subcutaneous tissue plane, and the standing
cutaneous deformity that develops inferiorly from the
advancement of wound margins is removed. Depending
on the shape of the flap, the lateral border of the donor
site may be considerably longer than the medial border.
If this is the situation, it may be necessary to excise an
additional standing cutaneous deformity (an equalizing
Burow triangle) at right angles to the melolabial closure.
This is accomplished at the inferior pole of the wound.
Cheek flaps are inset 3 weeks after transfer. For sub­
cutaneous tissue pedicled flaps, the pedicle is transected
at the base, and the cheek skin is undermined for a dis­
tance of 2 cm around the periphery of the wound. After
re-excision of the skin margins with a scalpel, the wound
is closed by advancing the borders together (see Fig.
18-28). As this is accomplished, it is usually necessary to
open the superior end of the donor site scar to facilitate
excision of redundant subcutaneous tissue and a small
standing cutaneous deformity that often forms as the
wound margins are approximated.
The proximal portion of the flap attached to the nose
is released from attachments to the adjacent nasal skin for
a distance of 0.5 to 1.0 cm to achieve sufficient freedom
to unfurrow the flap. Release enables the surgeon to