Nasal Reconstruction Art and Practice E-Book_nodrm

373
Figure 16–10
A
B
The FAMM Flap

374
Chapter • 16 • Restoring Nasal Lining — Use of a Second Flap for Lining
At an initial operation (Figure 16–11), the relatively normal but over rotated tip complex
was released. A full-thickness transverse incision across the nasal bridge, above the
intact tip subunit, allowed it to be caudally rotated. The residual normal tip was repo-
sitioned inferiorly. This created a full-thickness defect fl ap of the midvault. Midvault
lining was restored with a facial artery myomucosal fl ap, based on the left facial artery.
A FAMM fl ap, based superiorly under the left ala, was swung upward and passed into
the nasal cavity to line the nose. It was passed through a tunnel into the nose and
draped from left to right to line the middle vault. Its external surface was temporarily
skin grafted.

375
Figure 16–11
The FAMM Flap
A
B
C
D

376
Chapter • 16 • Restoring Nasal Lining — Use of a Second Flap for Lining
Figure 16–12
A
B
C
D
Eight weeks later (Figure 16–12), the skin graft was excised. The dorsum was supported
with a rib osteocartilaginous graft, fi xed to the nasal bones, as a central cantilevered
support. This shaped the bridge and braced the nasal length. The tip was supported
and shaped with a columellar rib strut, fi xed to the nasal spine through a buccal inci-
sion. The alar cartilages were, fi rst, advanced upward on the columellar strut. The tip
graft was positioned through transverse columella and rimming incisions. The missing
dorsal skin was replaced with a full-thickness paramedian forehead fl ap. Although the
forehead was short and tight, transposition was easily accomplished. No premaxillary
graft was required.

377
The FAMM Flap
Figure 16–12, Continued
E
F
Four weeks later, the forehead fl ap was re-elevated, during an intermediate operation,
to allow soft tissue sculpture of the excess bulk and further defi nition of the dorsal
lines and sidewall. Adding incisions along the superior aspect of both nasolabial folds,
small cheek fl aps were rotated and advanced upward on the sidewalls to limit the
dorsal skin defi ciency, as much as possible, to the dorsal unit alone. The forehead fl ap
was returned to its recipient site and its pedicle divided 3 weeks later.

378
Chapter • 16 • Restoring Nasal Lining — Use of a Second Flap for Lining
Postoperatively (Figure 16–13) forehead and nasal scars are inconspicuous, the overall
dimension of the nose and position of the tip are satisfactory. Absolute defi ciency of
nasal lining or external skin must be recognized and replaced. Only then can a skeletal
framework support, shape and brace the nose.
No revisions were performed.
Figure 16–13
A
B

379
The use of a second vascularized fl ap for nasal lining can be very useful in three
situations:
1. The inferiorly based septal composite fl ap can provide lining and central dorsal
support. Its vascularized mucosa can be turned laterally to line the middle vault
and the lateral aspects of the vestibule. It is not long enough to reach the alar
base, however. To complete the alar lining, a subcutaneously based nasolabial
fl ap, supplied by the underlying perforators of the facial artery (or a remnant of
residual ala) must be added to augment lining for the alar base. Most often, the
septal composite fl ap is pulled forward out of the nasal cavity to rest superiorly
on a shelf of nasal bone, at the radix. A nasolabial fl ap is simultaneously ele-
vated and folded on itself at the alar base, like a caterpillar. Four to six weeks
later, once the vascularity of both fl aps is assured, the septal mucoperichon-
drium is incised along the anterior free edge of the septal fl ap. It is turned
laterally and sutured to the lining of the upper aspect of the pyriform aperture.
Inferiorly, the septal mucoperichondrium is swung laterally to line the nasal
vestibule and medial aspect of the inferior nose. The nasolabial fl ap, positioned
at the alar base, is unraveled, thinned and swung medially to meet the septal
fl ap and complete the lining for the middle vault and vestibule (see Chapter 17).
2. In complex cases, when additional lining is required to line a small isolated
defect of the lateral alar base, a nasolabial fl ap can be effective, if other less
bulky options are unavailable.
3. Infrequently, lining loss is the primary nasal injury. Isolated injury may be
secondary to cocaine abuse, infection (syphilis, leprosy, yaws, leishmaniasis) or
autoimmune disease (Wegener granulomatosis, scleroderma). Lining necroses;
the septal cartilage becomes exposed. Secondary infection follows with collapse
and scar contraction. The late result is a foreshortened saddle nose.
In these circumstances, lining and support may remain the primary defi ciencies. When
only the lining and a support framework are missing, only these layers require replace-
ment. Fortunately, if the external nasal skin is relatively uninjured, it can often be
reexpanded without adding skin to the nasal surface. A nasolabial fl ap, second fore-
head fl ap, FAMM fl ap or free fl ap should be considered for lining. A forehead fl ap is
used for covering skin, if needed.
The FAMM Flap

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Restoring Nasal Lining —
Intranasal Lining Flaps
C H A P T E R
17
Although not apparent at fi rst glance, residual normal lining remains within the nasal
cavity and can be pulled out from the interior to line a full-thickness defect.
Stratifi ed squamous and mucoperichondrial intranasal fl aps can be transposed, based
on the facial and angular arteries, the septal branch of the superior labial artery, or the
anterior ethmoidal vessels.
As illustrated in Figure 17–1, the nose is perfused laterally from branches of the facial
and angular arteries. They supply the ipsilateral alar base and middle vault.
The centrally placed septum is perfused inferiorly, from bilateral septal branches of
the superior labial arteries, which arise from the facial artery. The superior labial artery
passes medially through the orbicularis oris muscle within the upper lip. Traveling
along the skin vermilion junction, the septal branch of the superior labial artery arises
Figure 17–1
A
Medial internal nasal branch
anterior ethmoid artery
Septal branch
posterior ethmoid artery
Posterior septal branch
sphenopalatine artery
Greater
palatinea
Labial artery branch
to anterior septum
C
B
Anterior
ethmoid
branch
Septal branch
superior labial artery
Facial
artery
Angular artery
Facial artery
Superior labial
artery
Septal branch
superior labiala

382
Chapter • 17 • Restoring Nasal Lining — Intranasal Lining Flaps
just lateral to the philtrum column and moves vertically upward, lateral to the nasal
spine, to supply the ipsilateral nasal septum. It then forms the anterior septal plexus.
It is located at the base of the columella within 1 to 1.2 cm of the nasal spine between
the anterior plane of the upper lip and the inferior edge of the piriform aperture. Each
septal mucoperichondrial leaf is perfused by its ipsilateral branch of the superior labial
artery. Each vessel perfuses the cartilage that lies between the two leaves of the septum.
The septum is a composite vascularized ‘septal sandwich’ of support and bilateral
lining.
Each side of the septal mucosa can be elevated based on its ipsilateral septal branch.
The bilateral blood supply allows both sides of the septal mucoperichondrium to be
mobilized on bilateral superior labial arteries. The septum can be transposed as a fl ap
of septal cartilage, lined by bilateral fl aps of mucoperichondrium.
The dorsal aspect of the septum is perfused by the paired anterior ethmoidal vessels
which, pass from under the nasal bones. They provide a blood supply from an antero-
superior direction to vascularize each side of the septum, dorsally. The right or left leaf
of the septal mucosa is perfused by the corresponding anterior ethmoidal artery.
Intranasal lining fl aps (Figure 17–2) can be raised on axial branches of facial and
angular arteries, septal branches of the superior labial artery or anterior ethmoidal
vessels. They can be positioned to line the nostril margin, dorsum, or lateral nose.

383
Restoring Nasal Lining — Intranasal Lining Flaps
Figure 17–2
B
D
A
C
1. Bipedicle flap:
3. Contralateral

septal flap
Ipsilateral septal
muco-perichondrium
incised as slit
Contralateral muco-perichondrium
pulled through incised ipsilateral
muco-perichondrium
Ipsilateral
mucoperichondrium
Contralateral
perichondrial
flap
2. Ipsilateral flap
Ipsilateral
septal flap
Septal cartilage
fashioned as sidewall
cartilage graft

384
Chapter • 17 • Restoring Nasal Lining — Intranasal Lining Flaps
E
F
Composite flap:
Mucoperichondrium
and septum
Pedicle
Septal branch from
superior labial artery
Fixation point
Future cartilage
trim
Figure 17–2, Continued
Intranasal lining fl aps are thin, supple, and vascular. Remember, however, that intra-
nasal lining fl aps are soft and fl imsy. They must be supported, shaped, and braced by
a support framework. In turn, the lining fl aps vascularize the overlying cartilage
framework.
When designed with a subunit shape, these cartilage grafts create a subsurface hard
tissue architecture which molds the covering skin into a nasal shape (Figure 17–3).

385
Restoring Nasal Lining — Intranasal Lining Flaps
Figure 17–3
Residual intranasal mucosa is perfused from multiple sources. It is moved to line a
defi ciency, based on the needs of the defect and the available blood supply. This is
determined by analyzing the location and size of the defect and the pedicle position,
dimension and reach of each individual lining fl ap. Obviously, these fl aps are
unavailable if prior surgery or traumatic injury has interrupted their named vessels or
severely disrupted their integrity. Damage to the dorsum and the middle vault may
injure the anterior ethmoidal vessels. The septal branch of the superior labial artery
may be destroyed in the vicinity of the nasal spine or more proximally within the lip.
The mucosa may be directly damaged by prior surgery or disease.
Unilateral septal mucoperichondrial fl aps, based on the right or left superior labial artery,
can be elevated off cartilage of the septum and transposed laterally and inferiorly to
line the vestibule and the lateral sidewall.
The ipsilateral septal mucosa can also be used in combination with a bipedicle vestibular
skin fl ap. If residual vestibular skin remains above a marginal defect, it can be incised
superiorly, creating a bipedicle fl ap. It is based medially on the septum and laterally
on the nasal fl oor. This bipedicle fl ap is perfused, medially, by the septal branch of the
superior labial artery and, laterally, by the branches of the facial and angular artery.

386
Chapter • 17 • Restoring Nasal Lining — Intranasal Lining Flaps
The fl ap is pulled inferiorly, like the hem of a skirt, to line the nostril rim. The superior
defect, created by advancement of the bipedicle fl ap, is fi lled with an ipsilateral septal
fl ap.
The defect, above a bipedicle vestibular rim fl ap, can also be fi lled with a contralateral
mucoperichondrial fl ap, based on the dorsum of the septum. Contralateral septal mucosa
is hinged laterally, based on branches of the anterior ethmoidal vessel. It lines the
remaining defect above the rim fl ap.
It was originally described by deQuervain as a composite chondromucosal fl ap. The
ipsilateral septal mucosa was elevated or discarded and the fl ap, containing cartilage
and contralateral septal mucoperichondrium, was swung laterally. It was popularized
by Kazanjian and used extensively by Gillies, Converse and Millard. However, it is
more practical to remove the septal cartilage, preserving a septal cartilage ‘L’. Then the
contralateral septal mucosa is transferred as mucosa alone. The harvested septal carti-
lage is shaped and reapplied to support to the mucosal fl ap without the restraints of
a composite fl ap.
The contralateral septal fl ap can be used to restore lining to an isolated defect of the
midvault or applied to fi ll the gap above a bipedicle vestibular fl ap or an ipsilateral
chondromucosal lining fl ap which has been transferred to line the inferior nose.
The paired septal branches of the superior labial artery lie close together near the nasal
spine. This allows the entire septum to be elevated as a composite septal fl ap. The septum
is swung out of the pyriform aperture to transpose a ‘septal sandwich’ of support and
lining, anterior to the plane of the face.
If a central nasal defect exists, a bilateral fl ap of mucoperichondrium and septal carti-
lage is pivoted anteriorly, out of the nose, to recreate central support and to provide
lining to the vestibules and columella, the middle vault or the entire nasal dorsum.
Hett, in 1917, described both superiorly- and inferiorly-based septal fl aps for nasal
support.
Millard, in 1967, described a superiorly-based composite fl ap. He incised the residual
septum as a full-thickness ‘L’ shaped fl ap. It was swung out of the pyriform aperture,
based on a random blood supply at the nasal root. Remaining elements of the anterior
ethmoidal arteries may contribute to its vascularity but the fl ap is somewhat tenuous
and often random. This design can supply dorsal and columellar support. Unfortu-
nately, it provides little extra lining and its vascularity is poor.
For unilateral defects of the inferior nose, Millard also turned the ipsilateral septal
mucoperichondrium, inferiorly. The septal mucosa was incised internally and folded
from back to front. Its blood supply was not identifi ed. He used it to line the nasal
vestibule.
Applications
Unilateral defects of the lower one third to one half of the nose:
1. Isolated unilateral defect of the midvault — contralateral septal mucosal fl ap.
2. Unilateral defect of the lower one third of the nose — bipedicle vestibular fl ap and
ipsilateral septal fl ap.
3. Unilateral defects up to one half of the nose — bipedicle vestibular fl ap and contra-
lateral septal fl ap.

387
4. Unilateral defects of the vestibule, middle and upper vaults — ipsilateral and
contralateral septal fl aps.
Central full-thickness defects of the upper, middle and lower nose:
1. Central defect of the dorsum and tip — septal composite fl ap.
2. Central defect combined with lateral ala lining loss — septal composite fl ap and
turnover alar remnant or nasolabial fl aps.
Isolated unilateral midvault lining loss-contralateral septal fl ap
Occasionally, a defect lies within the midvault alone. The inferior nose remains intact.
The residual ala may fall inferiorly, displaced by gravity. The defi ciency remains above.
Or it may retract superiorly, due to scar contraction, and retract the alar remnant
upward.
To repair the midvault, the contralateral septal mucoperichondrium can be harvested
through the full-thickness defect which follows the cancer excision or trauma. Or it can
be approached through a gap recreated by releasing the retracted nasal remnant and
allowing it to fall inferiorly.
If the ala is intact but malpositioned superiorly by scar or prior excision, it is released
and repositioned in symmetry to the opposite side. The ipsilateral septal mucoperi-
chondrium is visible through the wound. It is incised transversely under the dorsum,
exposing septal cartilage. The ipsilateral mucosa is elevated. Preserving 8 to 10 mm to
support the dorsum, the septal cartilage is incised transversely in line with the anterior
dorsal edge. Central septal cartilage is harvested for graft material. The contralateral
mucosa is preserved and the anterior ethmoidal vessels are protected. The contralateral
septal mucosa is then elevated.
A dorsally-based fl ap of contralateral septal mucosa is incised, maintaining its dorsal
blood supply from the contralateral anterior ethmoidal vessels. The contralateral fl ap
is then passed through the dorsal slit, created in the ipsilateral septal lining. It is pulled
laterally and sutured to the periphery of the midvault lining defect. The opening within
the ipsilateral septum remains unrepaired but is functionally insignifi cant. The raw
surface of the ipsilateral fl ap, which now lies exposed within the contralateral airway,
heals spontaneously. Harvested septal cartilage and bone is then fashioned to create a
sidewall brace which supports and shapes the midvault and prevents the ala from
retracting upward, postoperatively. Missing external skin is advanced from the cheek
or transposed from the forehead to resurface the repair.
Applications

388
Chapter • 17 • Restoring Nasal Lining — Intranasal Lining Flaps
This patient’s left ala is retracted and nostril is stenosed (Figure 17–4).
Multiple skin cancer defects had been repaired in the past. The external nose had been
resurfaced with a bilobed fl ap, several skin grafts, and a left alar subunit two-stage
nasolabial fl ap. A later Mohs defect of the left vestibular lining, due to melanoma in
situ, had been skin grafted.
The following operation was undertaken (Figure 17–5): the old bilobed fl ap, skin graft,
the alar nasolabial fl ap and the regional units are marked with ink. A full-thickness
incision was made at the junction of the reconstructed left ala and sidewall. The ipsi-
lateral septal mucosa was incised under the dorsum and elevated from the septum,
subperichondrially. Maintaining septal dorsal support, the septal cartilage was incised
below the bridge. Septal cartilage was harvested, as in an SMR, for graft material. The
contralateral septal mucoperichondrium was elevated off the contralateral surface of
the septum and was incised superiorly, inferiorly and posteriorly. The contralateral
septal mucoperichondrium remained perfused anteriorly, along the dorsum, through
the anterior ethmoidal vessels. The fl ap was pulled through the left septal mucosal slit
and sutured to fi ll the left sidewall lining defi ciency. A septal cartilage sidewall graft
was fi xed to the mucosal fl ap with fi ne suture to support, shape and strengthen the
repair against wound contracture. The alar skin was also elevated inferiorly along the
wound margin. A conchal cartilage graft was placed within a subcutaneous pocket to
support the ala.
A
B
Figure 17–4

389
A
B
C
Figure 17–5
Applications

390
Chapter • 17 • Restoring Nasal Lining — Intranasal Lining Flaps
The left nasolabial fold was incised (Figure 17–6). The cheek was elevated and advanced
to resurface the sidewall skin defi cit. It positioned the scars along the dorsal sidewall
join. The advanced cheek skin was approximated to the nasal surface with quilting
sutures and the skin edges were closed with fi ne sutures.
Although improved, the left alar margin remained retracted. The left alar crease was
poorly defi ned (Figure 17–7).
Based on a template of the contralateral normal right ala, the left alar subunit was
marked with ink. Disregarding old scars, an incision was made in the ideal join
between the ala and sidewall. Subcutaneous tissue and cartilage was excised to create
the contour of the ala and its crease. The edge of the alar skin was fi xed to the depth
of the crease with 6-0 absorbable sutures. The skin was then reapproximated. A con-
tralateral right nasolabial fold excision was also performed for symmetry.
Figure 17–6

391
Figure 17–7
A
B
Applications

392
Chapter • 17 • Restoring Nasal Lining — Intranasal Lining Flaps
During the same procedure (Figure 17–8), the nostril margin was incised and excess
subcutaneous bulk was excised medial to the old cartilage graft. The skin of the old
nasolabial fl ap, which had been pulled inward by scar contracture of the previous
vestibular skin graft, was unfolded along the rim. A chondrocutaneous composite graft
from the concha was sutured along the left alar rim to supply additional lining.
Nasal position, symmetry and contour have been restored (Figure 17–9).
A
B
C
D
Figure 17–8

393
A
B
C
Figure 17–9
Applications

394
Chapter • 17 • Restoring Nasal Lining — Intranasal Lining Flaps
Unilateral lining defect of the lower one third of the nose — bipedicle
vestibular fl ap and ipsilateral septal fl ap
If a unilateral defect of the nostril margin is less than about 1 cm in height, a signifi cant
amount of residual stratifi ed squamous skin remains above the defect. A bipedicle fl ap
of remnant vestibular skin, between the edge of the defect and the internal nasal valve,
can be moved caudally to line the nostril margin. Medially, the fl ap is perfused through
its connection to the ipsilateral septal lining at the septal angle, with which it is
in continuity. Laterally, it receives its blood supply through multiple branches of the
facial and angular arteries at the alar base. The bipedicle fl ap was fi rst described by
Burget.
The secondary defect, which results from the advancement of the bipedicle fl ap, is fi lled
with an ipsilateral septal fl ap. It can also be replaced with a skin graft (see Chapter 19).
This bipartite lining fl ap consists of a strap-like component of vestibular skin which
spans the defect from the septal angle to the alar base and a second component of
ipsilateral septal mucosa which is advanced out of the nose, to fi ll the superior aspect
of the lining defi ciency. The vestibular bipedicle is advanced inferiorly and the ipsilat-
eral septal mucosa is swung out and over to create a lining sleeve for the nasal vestibule
and the inferior sidewall.
The vestibular fl ap has the advantage that its dry stratifi ed squamous epithelium is
less easily traumatized than septal mucosa, which can appear abnormally red postop-
eratively, secrete mucus, crust and bleed, if abraded.
The requirements of the wound are determined. Local anesthesia with epinephrine is
injected sparingly across the nasal vault and more aggressively within the septum. A
bipedicle fl ap, 8 mm wide, is designed within the existing lining, just above the defect.
The incision of the fl ap’s superior margin (similar to the intercartilaginous incision of
an aesthetic rhinoplasty) is carried through the vestibular lining into the overlying soft
tissues. It may include a small component of the lateral crus of the alar cartilage. The
middle crus of the alar cartilage may have to be divided to mobilize the fl ap adequately.
It is separated from the overlying subcutaneous tissue. Hinged medially and laterally,
the bipedicle is pulled inferiorly, to the level of the proposed nostril rim. Small kinks
may develop at each base as the fl ap buckles. They are ignored.
The ipsilateral septal fl ap, which measures up to about 3 × 3 cm in width and length,
is outlined with ink. It passes towards the medial canthus about 6 to 8 mm below the
dorsum, travels posteriorly with a right angle to the nasal fl oor and then proceeds
anteriorly towards the nasal spine. It is incised longitudinally with straight scissors. Its
distal end is cut with a right angle scissors. A 1.2-cm soft tissue pedicle is maintained
in the vicinity of the nasal spine directly over the soft tissues of the lip. It contains the
fl ap’s axial blood supply.
The mucoperichondrium is elevated off the cartilage and bone of the septum, as in a
submucous resection. The size of the septal fl ap is primarily limited by the surgeon’s
ability to incise within the confi nes of the piriform aperture. It can extend up to the
medial canthi and inferiorly to the nasal fl oor. Its elevation exposes ethmoid bone and
septal cartilage. Leaving a strong septal ‘L,’ the central septal cartilage is harvested for
graft material.
The bipedicle fl ap is advanced inferiorly. The ipsilateral fl ap is swung off the septum.
It is sutured to the superior aspect of the defect, laterally along the pyriform aperture

395
and inferiorly to the bipedicle fl ap. This creates a complete lining sleeve for unilateral
nasal defect.
A recurrent basal skin cancer was excised from the tip, dorsum, sidewall and the left
ala of this patient (Figure 17–10). The left alar base was distorted by a previous excision
and poorly designed left nasolabial repair. Although this defect is larger than most
which are repaired with a bipedicle vestibular fl ap, residual lining remained above the
ablated rim.
Figure 17–10
Applications

396
Chapter • 17 • Restoring Nasal Lining — Intranasal Lining Flaps
As illustrated in Figure 17–11, lining above the defect was undermined and then
incised transversely to create a bipedicle fl ap. It was transposed to the proposed alar
rim. The ipsilateral septal mucosa was elevated off the septal cartilage and carried
across the nasal airway to fi ll the lining defect which remained above the bipedicle
lining fl ap. Septal cartilage was harvested for graft material. Once sutured together,
the restored lining sleeve was shaped by subunit primary cartilage grafts. A forehead
fl ap resurfaced the nose in three stages.
A
C
B
Mucosal
incision
Lining lacks
support
Figure 17–11

397
E
D
Figure 17–11, Continued
Applications

398
Chapter • 17 • Restoring Nasal Lining — Intranasal Lining Flaps
The forehead skin surface is shiny and more atrophic than nasal skin, perhaps due to
previous application of 5FU for actinic changes of the forehead. The nostril was revised
4 months later by local lining redistribution (see Figure 17–12).
Unilateral lining defects for up to one half of the nose: bipedicle
vestibular fl ap and contralateral septal fl ap
In larger defects, although the bipedicle fl ap may remain available, the secondary
defect becomes too large to be replaced with an ipsilateral septal mucosal fl ap. The
length of an ipsilateral fl ap is limited by the twist of its pedicle. Its width may not be
adequate to fi ll the height of the residual defect. A contralateral septal fl ap, fi rst
A
B
C
Figure 17–12

399
described by deQuervain as a composite fl ap of septal mucosa and underlying carti-
lage, can satisfy the needs of the recipient site.
First, a bipedicle fl ap of vestibular skin and mucosa is swung inferiorly, like a visor or
bucket-handle, from the margin of the defect. The ipsilateral septal mucosa is incised
below the dorsum and elevated subperichondrially in line with the nasal bridge. The
underlying septal cartilage is incised, protecting the contralateral mucosa. Septal car-
tilage is harvested; leaving a strong ‘L’ strut for support. The contralateral septal
mucoperichondrium is then incised to develop a dorsally based fl ap, perfused by the
anterior ethmoidal vessels. It measures approximately 2.5–3 × 3 cm. The dorsal mucosa
is left intact while two parallel cuts are directed towards the fl oor of the nose. The fl ap’s
distal end is then incised along the nasal fl oor. The contralateral mucosal fl ap is pulled
through the ipsilateral mucosal slit to line the middle vault and the superior aspect of
the vestibule. The contralateral fl ap is sutured to the upper aspect of the defect, later-
ally along the piriform aperture and, inferiorly, to the superior aspect of the bipedicle
fl ap. This creates a complete lining sleeve. Practically speaking, this is exactly like our
earlier case (Figure 17–4).
The dorsally based, contralateral septal fl ap can be designed, if needed, to extend onto
the nasal fl oor. This increases its length and allows it to reach across the midline to the
lateral aspect of the pyriform aperture. A wide fl ap can be designed along the entire
dorsum to ensure it will have adequate vertical dimension to fi ll the height of the
defect.
DeQuervain described this fl ap as a composite fl ap of contralateral septal mucosa with
its adherent cartilage. Such a fl ap, however, is unwieldy and limits the ability of the
surgeon in design and transposition. Excision of the ipsilateral septal lining or exten-
sive septal mucosal incisions is needed to expose, elevate and transfer this thick stiff
fl ap. It creates extensive scars or a septal fi stula. Such dissection is unnecessary and
avoidable.
First, incise only a slit under the ipsilateral dorsum. Then harvest the septal cartilage.
Then incise and transpose the contralateral mucosa. The transfer of mucosa alone is
easier. Cartilage can be harvested more completely. It is more easily designed and
positioned to provide support. It can be thinned, bent with sutures and shaped in the
dimensions that best suit the defect.
Note, however, that the contralateral septal fl ap cannot line the nostril margin. Teth-
ered by its dorsal attachment and limited by the length of the septum at the septal
angle, it does not have the length or width to reach inferiorly to the nostril rim. It must
be combined with a bipedicle vestibular fl ap to line the nostril margin. A moderate
sized unilateral defect, which extends inferiorly to the nostril margin, requires a con-
tralateral septal fl ap and a bipedicle rim fl ap.
Unilateral lining of the vestibule, middle and upper vaults:
ipsilateral and contralateral mucosal fl aps
If the lining defi cit extends from the nostril margin to the nasal bones, an ipsilateral septal
mucoperichondrial fl ap is used to line the nostril margin inferiorly. A contralateral septal
mucosal fl ap is simultaneously employed to line the middle and upper vaults. This
creates a large permanent septal fi stula. Fortunately, such fi stulas are well tolerated.
After injecting the septum with dilute epinephrine bilaterally, the mucoperichondrium
is dissected off the entire ipsilateral septum, as in a SMR. The mucosa can be elevated
Applications

400
Chapter • 17 • Restoring Nasal Lining — Intranasal Lining Flaps
from the superior border of the dorsal septum. The subsequent ‘L’ strut will be envel-
oped by the contralateral septal fl ap as it swings to the opposite side of the nose. It will
prevent late cartilage exposure on the ipsilateral side.
The distal border of the ipsilateral fl ap is cut with right angle scissors about 1 cm below
the level of the medial canthus. A parallel incision is then made close to the nasal fl oor,
extending forward towards the nasal spine. The fl ap’s vascular pedicle is approxi-
mately 1.2 cm in width. It is centered over the soft tissue of the upper lip at the nasal
spine. The fl ap is swung laterally to expose the quadrilateral cartilage, ethmoid and
vomer. Preserving an 8 to 10-mm wide L-shaped strut of cartilage to maintain dorsal
and caudal support, septal cartilage and bone are harvested for graft material. The
contralateral mucoperichondrium is preserved.
Based on the dorsum of the septum, a contralateral septal fl ap is designed. The con-
tralateral fl ap is about 2 cm wide and 3 cm long. Maintaining a dorsal pedicle, it is
incised inferiorly, superiorly, and posteriorly onto the nasal fl oor. Irregular spicules of
exposed bone and cartilage are trimmed back. Where possible, the raw edges of septal
donor site are closed by mucosal to mucosal approximation with 4-0 gut sutures. Areas
along the nasal fl oor, or deep within the nose, or within the narrow upper reaches of
the nasal cavities are left to heal spontaneously. Gelfoam can be placed along the
wound edges to minimize oozing. Occasionally, if bleeding is a concern, the nose can
be packed with petrolatum gauze for 5 days.
The ipsilateral septal fl ap is rotated up and out and then draped laterally towards the
alar base to line the vestibule. The contralateral dorsally-based septal fl ap is passed
through the septal fi stula and sutured to the lateral edge of the nasal defect. The lower
edge of the contralateral fl ap is sutured to the upper edge of the ipsilateral fl ap, com-
pleting the repair. The pedicle of the ipsilateral fl ap may partially obstruct the nasal
airway. Once healed, it can be divided, opening the airway.
This patient’s original heminasal defect extended over the dorsum, tip, sidewall, ala,
and medial cheek (Figure 17–13). In a preliminary procedure, the right cheek was
advanced to the piriform aperture and the nasal dorsum was skin grafted (see
Chapter 3).
Figure 17–13

401
The following operation was performed (Figure 17–14): the ipsilateral septum was
elevated as a chondromucosal fl ap perfused by the septal branches of the right superior
labial artery. It was incised peripherally except for a 1.2-cm pedicle centered on the
nasal spine. Maintaining a 1 cm dorsal and caudal ‘L’ strut, the central septal cartilage
was harvested for graft material. The contralateral septal mucosa was incised inferiorly
and posteriorly, maintaining the anterior ethmoidal vessels dorsally. The contralateral
septal fl ap was pulled through the septal fi stula and sutured to the right pyriform
margin to line the middle and upper vault. The ipsilateral fl ap was transposed laterally
and sutured to the lining of the residual alar remnant and to the piriform aperture.
Both fl aps were sutured to one another to form a complete lining sleeve for the right
heminose. Primary cartilage ear and septal grafts were placed to support the dorsum,
sidewall, tip, and ala. A three-stage forehead fl ap covered the repair.
A
Ipsilateral
septal flap
elevated
Contralateral septum
hinged and swung
up to side wall
Septal bone and
cartilage harvested
Hinge
Contralateral
perichondrium
based on dorsum
Dorsal cartilage
strut
Septal cartilage
removed
Dorsal
cartilage strut
Figure 17–14
Applications

402
Chapter • 17 • Restoring Nasal Lining — Intranasal Lining Flaps
B
C
D
E
Figure 17–14, Continued

403
F
G
H
I
Figure 17–14, Continued
Applications

404
Chapter • 17 • Restoring Nasal Lining — Intranasal Lining Flaps
No revisions were performed (Figure 17–15).
Central full-thickness defects of the upper middle and lower nose
The high, converging medial and lateral walls of the upper and middle vaults permit
the repair of modest lining defects of the superior nose by simple side-to-side approxi-
mation. The residual lateral sidewall mucosa is sutured to the medial septal muco-
perichondrium. This may lower the dorsal height of the nasal vault, especially if the
nasal bones or dorsal septum have been injured. However, as long as the loss of the
middle or upper vault is modest, nasal breathing is not signifi cantly diminished. Once
lining is repaired, bone or cartilage grafts can be shaped to replace the missing nasal
bones or upper lateral cartilage, reestablishing shape and dimension to the nasal bridge
and sidewalls. A forehead fl ap supplies external skin.
Reconstruction is more complicated when the inferior nose and tip are missing.
A
B
Figure 17–15

405
These signifi cant central nasal defects are classifi ed as subtotal (parts of the projecting
septum and bones at the radix are preserved) or total (loss of all soft tissue structures,
anterior septum and nasal bones fl ush with the frontal bone of the maxilla).
Fortunately, a large part of the anterior septum often remains uninjured, within the
pyriform aperture or protruding from the facial plane. The residual septal partition can
be pulled out, to line the projecting parts of the nose. Its septal support can be used as
a foundation on which to rest a dorsal strut.
The repair is even more daunting when the anterior projecting septum is missing, fl ush
with the midface. Fortunately, the deeper septum almost always remains intact within
the pyriform aperture. It may be absent, however, after severe facial trauma or the
resection of intranasal squamous cell carcinoma.
The loss of the nasal bones is especially signifi cant because they provide the fulcrum
on which to fi x a cantilevered bone graft. A rigid dorsal graft is needed to restore the
nasal dorsal profi le and width. If the nasal bones are absent, it is diffi cult to stabilize
a dorsal support framework.
Traditional methods replaced lining in such defects with hingeover fl aps of residual
external skin, turn-over nasolabial fl aps, or forehead fl aps prelaminated with skin
grafts. However, they are poorly vascularized. Their viability is suspect and they do
not reliably nourish primary bone cartilage grafts. Graft exposure leads to infection,
extrusion, scarring and retraction.
Millard championed the repair of these diffi cult total nasal defects. During a prelimi-
nary operation, he constructed a bony fulcrum at the radix with local hingeover lining
tissues and a bone graft, covered by a median forehead fl ap. In other cases, he employed
a superiorly based L-shaped full-thickness septal fl ap which was hinged out of the
pyriform aperture to re-establish limited dorsal and caudal septal support and lining.
Later, hingeover fl aps of local tissue and bilateral nasolabial fl aps were turned inward
to line the midvault, ala and columella. A cantilever bone graft was anchored to the
preplaced fulcrum to establish dorsal support, and a second forehead fl ap was used
for cover.
The septal composite fl ap, described by Burget and Menick, is a better solution. In most
nasal injuries, a signifi cant portion of the septum remains and projects from the facial
plane. Even, in more signifi cant defects when the septum is cut off fl ush with the face,
the deeper septum usually remains intact within the pyriform aperture. It can line
subtotal and total losses. The septal composite fl ap swings the residual septum out
and provides support along the dorsum and excess septal mucosa to line the inferior
nose. Its inferior base is perfused by the bilateral septal branches of the superior labial
arteries, at the nasal spine. It provides thin, supple, vascularized lining and central
support to the nasal vestibules, the middle and upper vaults.
A composite septal fl ap, based bilaterally on the superior labial arteries, mobilizes the
entire septum out of the nasal cavity and projects it in front of the face. This positions
a vertical sheet of bone and cartilage which can support the dorsum of the nose. A
dorsal costochondral rib graft is positioned on this hard tissue base and fi xed to the
residual nasal bones at the radix. Bilateral fl aps of excess septal mucosa are hinged
laterally to line the lateral aspects of the defect. If the radix is missing, a bony fulcrum
might be re-established during a preliminary operation, as recommended by Millard.
Plate and screw fi xation would likely be the more modern choice to stabilize the dorsal
bone graft, superiorly.
Applications

406
Chapter • 17 • Restoring Nasal Lining — Intranasal Lining Flaps
The outline and dimensions of the septal fl ap are marked with ink. In such defects,
exposure is not the problem. It is then injected with dilute epinephrine solution. The
full-thickness of the septum is cut with a straight scissors or knife at its superior and
inferior edges. Distally, it is transected with a right angle scissors. The mucosa is pre-
served in the region of the nasal spine and upper lip. The right and left septal branches
of the superior labial arteries must remain intact. They are preserved in the 1.2-cm soft
tissue pedicle, which contains the fl ap’s blood supply.
However, after these full-thickness incisions, the fl ap will not move out of the piriform
aperture. It remains restrained by the attachments of the septal cartilage to the nasal
spine. At the base of the fl ap, mucoperichondrium must be separated on each side of
the cartilaginous septum to allow removal of a small wedge of bone and cartilage over
the nasal spine. This is removed with a knife or rongeur. The septal composite is then
drawn out of the nasal cavity, on its soft tissue tether. It is pulled from the nose and
rests, superiorly, on the residual shelf of upper lateral cartilage or nasal bones. The
distal (now superior) aspect of the fl ap is anchored to the stumps of the upper lateral
cartilage or to the nasal bones with polypropylene or wire suture. The intranasal donor
site is closed, posteriorly and inferiorly, by mucosa to mucosa repair. Exposed spicules
of bone or cartilage are removed. Closure of the donor defect within the upper nasal
cavity is incomplete. The raw, dorsal aspect of the fl ap is closed with mucosa to mucosa
sutures.
If the nasal defect is limited to the upper or midvault, the composite fl ap restores the
central bony platform. Then the mucosa of the right and left sides of the septum is
refl ected laterally and sutured to the lateral border of the defect. This lines the upper
and midvault and permits simultaneous placement of primary subunit cartilage grafts.
These grafts are designed to recreate a support framework wherever it is missing and
will be unique for each case. Then a forehead fl ap is applied for cover (see Chapter 8,
Fig 5–8).
In a subtotal or total nasal reconstruction when the upper nose, as well as the tip and
ala are missing, it is safer to stop the operation after mobilization of the septal com-
posite fl ap. This allows time to ensure its vascularization and allows it to heal to the
residual nasal root. The septal fl ap will tolerate more manipulation once it is healed in
place and is more stable.
Six to eight weeks later, at a second stage, the exposed dorsal mucosal edge is split at
its center, exposing the septal cartilage within. In the upper and middle nose, bilateral
lining fl aps are turned, like pages of the book, to reach the lateral margins of the
residual defect. Superiorly, the septal mucosa is suffi cient to line the upper and middle
vaults. However, more inferiorly, it will not reach around to the alar bases. The septal
composite fl ap does not supply enough mucosa to line the entire vestibule and ala.
However, the vascularity of the septal composite fl ap is profuse. The refl ected dorsal
mucosa can be incised and subdivided into a second transposition fl ap which can be
refl ected towards the tip. These little fl aps may supply additional lining for the medial
aspect of the nasal vestibule. However, if the lining loss extends laterally to the alar
base, additional lining must be supplied by hingeover fl aps, turned up from a residual
alar remnant or from a nasolabial fl ap. Presurgical delay of these local fl aps may
increase their vascularity. (If needed, it is wise to elevate and preposition these naso-
labial fl aps to a more superior and medial location, during a preliminary position.
Later, they will be available at the alar base to line the lateral aspect of the ala.) Once
sutured together, a highly vascular, supple, and thin lining sleeve is recreated. Primary
cartilage grafts are placed to support, shape and brace the repair.

407
A subtotal nasal amputation was required to treat squamous cell carcinoma of the
anterior septum (Figure 17–16). The nasal bones and remnants of the ala are intact. The
septal partition remains within the piriform aperture.
Figure 17–16
Applications
B
A

408
Chapter • 17 • Restoring Nasal Lining — Intranasal Lining Flaps
The septum was incised superiorly, posteriorly, and inferiorly to create a full-thickness
composite fl ap, hinged on a 1.2-cm pedicle of soft tissue at the nasal spine. This com-
posite fl ap was perfused through the septal branches of the right and left superior labial
arteries. The skin and mucosa was incised vertically in the midline, at the base of the
fl ap, to allow elevation of both leaves of mucosa and excision of a few millimeters of
septal cartilage. This allowed the fl ap to be hinged forward out of the piriform aperture
on a soft tissue leash of mucosa. After advancement of the fl ap, its superior edge was
sutured to the soft tissues about the nasal bones and residual upper lateral cartilages.
(See Figure 17–17.)
Figure 17–17
Single unit of right and
left mucoperichordrium,
bone and septal cartilage
advanced with blood supply
Excess cartilage trimmed
to new shape
Mucoperichordium
turned over to provide
lateral lining to both right
and left nasal vaults
A
B

409
C
D
Figure 17–17, Continued
Applications

410
Chapter • 17 • Restoring Nasal Lining — Intranasal Lining Flaps
Four weeks later (Figure 17–18), once vascularity was assured and the fl ap was healed
into position, the leaves of the right and left septum were separated dorsally and
hinged laterally. They were easily approximated to residual lining along the lateral
nasal wall. Dorsal excess was incised, as inferiorly based fl aps, based on the new nasal
tip. These were turned laterally to line the nasal vestibules.
A
B
C
D
Figure 17–18

411
E
Figure 17–18, Continued
Applications

412
Chapter • 17 • Restoring Nasal Lining — Intranasal Lining Flaps
A
B
Figure 17–19
However, the lining provided by a septal composite fl ap was not suffi cient to com-
pletely line the inferior nose. So previous delayed hingeover lining fl aps from the alar
remnants were turned over to supply lining to the alar base. If unavailable, nasolabial
fl aps can also serve this purpose. Once a complete lining sleeve was restored, rib car-
tilage grafts were employed to create a subsurface architecture. The nose was resur-
faced with a three-stage forehead fl ap.
A revision was performed to further defi ne the alar creases and open the airways with
local lining fl aps (Figure 17–19).
Creating a Subsurface Framework
Although signifi cant nasal lining can be provided by intranasal lining fl aps, it has no
shape or structure. It collapses onto the nasal fl oor. However, it has an excellent blood
supply.
But the fl aps are thin and pliable. Shapely and supportive subunit bone and cartilage
grafts are applied to these supple and well vascularized lining fl aps. This permits
immediate restoration of a subsurface architecture. The contour of the nasal tip is
restored with a columellar strut, Sheen or Peck tip grafts, or anatomic tip grafts. The
nasal sidewalls are braced and supported with replacements for the upper lateral
cartilage and nasal bone. The dorsal contour and support are restored with onlay car-
tilaginous buttresses or a dorsal graft cantilevered from the nasal root. The alar rim is
shaped and held open with a cartilage batten. Using hard tissue from the septum,

413
conchal cartilage from one or both ears, and, when necessary, a rib osteocartilaginous
graft or a cranial or iliac bone graft, a framework is created with a nasal shape. The
contour of these support grafts, as they show through conforming skin cover, creates
the lights and shadows of the normal nose. Once the contours are correct, the surgeon
can create a pattern for a forehead fl ap. It resurfaces this assembly of cartilage grafts
and intranasal lining.
Gillies and Millard have described plastic surgery as ‘the perpetual battle of beauty
versus blood supply’. However, when ‘making noses,’ the relationship of support and
lining is best described as a ‘love affair’. Cartilage grafts depend on lining for vascu-
larization; lining and cover are dependent on cartilage graft for support and contour.
This ‘marriage’ of primary cartilage grafts and thin vascular intranasal lining fl aps is
a happy one. They are ‘made for each other’. Like husband and wife, they cherish and
support from this day forward — if only properly introduced!
Advantages and Limitations of Intranasal Lining Flaps
The introduction of modern intranasal lining fl aps for lining revolutionized reconstruc-
tion. Although unappreciated in the past, signifi cant residual lining often remains
available within the nasal cavity to repair the nose. Based on known vascular pedicles,
it can be positioned outward and shared with the defect. For the fi rst time, reliable,
thin supple vascularized lining was available which would not stuff the airway or
distort the external shape. Equally important, primary cartilage grafts could be posi-
tioned to support, shape, and brace the repair at the initial stage. A fabricated frame-
work of hard tissue could be constructed with a shape, which appeared to be a nose,
when visible through a covering fl ap. Intranasal lining fl aps and primary cartilage
grafts, combined with thoughtful principles of repair, turned nasal reconstruction into
aesthetic nasal reconstruction. Nasal reconstruction became an intellectual, artistic and
surgical process. Regional unit principles could be applied to make nasal repair ‘a
thinking man’s game’.
However, the limitations of intranasal lining fl aps must be understood to ensure their
proper application.
1. Intranasal lining fl aps are limited in availability — their modest size, limited
reach or prior injury to their blood supply (due to trauma or previous operation)
may preclude their successful application.
2. Although highly vascular, they can be unpredictable in the smoker or in major
repairs when multiple lining fl aps are ‘pushed to their limits’ to repair large
defects. There is not much room for error when any diffi cult defect is repaired. A
minor cartilage exposure often progresses to infection.
3. Intranasal lining fl aps are somewhat fragile. They should be elevated sub-
perichondrially, as an SMR, to protect their blood supply. They must be sup-
ported and shaped by primary cartilage grafts.
4. The dissection required to elevate intranasal lining fl aps is destructive to the
nose and increases the overall morbidity of nasal repair. Temporary bleeding,
crusting and obstruction follow. In the elderly or debilitated patient, recovery
may be delayed. Fortunately, any surgically created fi stula heals spontaneously
around its border and the nose becomes self cleansing. Whistling does not occur
because of the fi stula’s large size. Crusting is minimal, once all raw areas
re-epithelialize.
Advantages and Limitations of Intranasal Lining Flaps

414
Chapter • 17 • Restoring Nasal Lining — Intranasal Lining Flaps
5. The use of intranasal lining fl aps, in major repairs, is relatively complex and
time-consuming. Multiple fl oppy fl aps are sutured together to form a lining
sleeve. They must be buttressed with multiple individual cartilage pieces, fi xed
together with suture. This fabrication of lining and support is a complex
construction.
6. In major repairs, the fi nal result may be marred by late retraction, external
distortion or narrowing of the airway. The lack of rigidity and limited
dimensions of intranasal lining fl aps, the relatively unstable cartilage
construction of multiple suture fi xated grafts, dead space, hematoma and
myofi broblast contraction may limit the fi nal results. Late nostril stenosis is not
uncommon.
In my current practice, when lining is missing, intranasal lining fl aps are rarely my
fi rst choice. A small marginal defect can be repaired with a composite skin graft.
Moderate unilateral defects are more conveniently repaired with a modifi ed folded
forehead fl ap technique. More complex defects may be repaired with a free fl ap for
lining. However, intranasal lining fl aps remain a valuable tool in the repair of isolated
midvault or large unilateral full-thickness defects, when other methods are less
applicable.

Restoring Nasal Lining —
the Folded Forehead Flap
for Lining; the Menick
Modifi ed Method
C H A P T E R
18
Folding the distal end of a forehead fl ap onto itself to supply both external cover and
internal lining is a traditional method. Unfortunately, it does not produce aesthetic
results. The reconstructed nose is thick, shapeless and unsupported. The airways are
collapsed and stuffed. The traditional method precludes shaped primary cartilage
grafts.
More recently, forehead skin has been transferred as a full-thickness forehead fl ap.
Forehead skin is moved in three operations, with an intermediate stage between trans-
fer and pedicle division. During the intermediate operation, the fl ap is debulked to
create thin supple cover. Primary and delayed primary cartilage grafts are combined
with extensive soft tissue sculpture to shape a subsurface framework, prior to pedicle
division. The technique increases the fl ap’s vascular safety and improves the fi nal
result. The need for late revisional surgery is minimized in major nasal defects — those
with large skin losses and those in which both skin and cartilage are missing.
Just as importantly, it became apparent that the three-stage technique lent itself to a
modifi cation of the traditional folded method of nasal lining. This modifi ed folded
lining technique provides a simple, effi cient and widely applicable method for lining
replacement which can be applied to the most common nasal defects.
The Menick Modifi ed Folded Flap for Nasal Lining
Principles and technique
1. The forehead is multi-laminar — thick and stiff due to its skin, subcutaneous fat,
frontalis muscle and underlying areolar layers.
2. A full-thickness forehead fl ap is highly vascular. The risk of necrosis is minimal.
It can be transferred and modifi ed intraoperatively, in stages, with little concern.
3. It can be folded to line itself. An exact pattern of the lining defect is outlined.
The lining replacement is added as an extension of a full-thickness forehead fl ap.
This lies in the area normally discarded, as a dog ear, on closure of the donor
site. The donor site suffers minimal extra injury. The cover template is posi-
tioned vertically over its supratrochlear artery base. Then the lining template is
drawn in continuity with the distal end of the covering fl ap, adding 2 to 3 mm
between both templates. This allows the fl ap to fold more easily during its inset.
Forehead height is not a limiting factor. If the lining template must extend into
the hairline, any transferred follicles simulate intranasal vibrissae and can be
trimmed postoperatively, if necessary.

416
Chapter • 18 • Restoring Nasal Lining — the Folded Forehead Flap for Lining; the Menick Modifi ed Method
4. The forehead fl ap, as a single cover and lining unit, is elevated, with all its
layers, from its distal end to its proximal base.
5. The distal lining extension of the full-thickness forehead fl ap is folded inward
and sutured to the residual mucosal lining of the defect with fi ne absorbable
sutures. The more proximal aspect of the fl ap is folded back onto itself to supply
nasal cover. It is sutured to the external skin of the recipient site in one layer.
This creates, in the area of folding, a layer of the external skin, subcutaneous fat,
frontalis and areolar tissue which rests against an inner layer of areolar tissue,
frontalis muscle, subcutaneous fat, and skin, which replaces the missing lining.
No primary cartilage support is placed within the folded fl ap. However, primary
cartilage grafts can be placed in neighboring areas of superfi cial injury, if normal
residual vascularized lining remains intact. For example, if the defect combines a
partial thickness defect of the tip with a full thickness defect of the ala, primary
cartilage grafts are positioned to repair the tip loss, where vascularized lining
remains. In the adjacent area of full thickness alar loss, only the lining is
replaced, with the distal extension of the forehead fl ap. The proximal fl ap is
folded back on itself to resurface the entire external skin defi ciency. However, no
cartilage is placed within the folded fl ap. Normally, the distal lining extension is
not thinned. However, some foreheads are stiffer than others and, at times, some
frontalis will be excised peripherally, if folding is diffi cult.
6. At a second stage, 3 to 4 weeks later, during an intermediate operation, the
forehead fl ap is physiologically delayed. Its blood supply is signifi cantly
augmented. The proximal aspect of the forehead fl ap, which was designed for
cover, can be widely re-elevated and ‘thinned,’ with impunity. Even more
importantly, its folded distal extension, which was designed to line the nasal
repair, is now integrated into the residual normal lining and is no longer
dependent on the proximal forehead fl ap and its supratrochlear pedicle for
blood supply.
7. Because the frontalis muscle is not excised or the subcutaneous plane of the fl ap
injured during transfer, its skin remains soft and supple. Wound contraction and
scarring are not present within the transposed fl ap. The transferred skin, which

417
restored both cover and lining, will conform to delayed primary cartilage grafts,
which are placed at the second stage. This shaped architectural
framework can shape the soft tissues.
The proposed nostril margin is marked with ink, based on templates of the
contralateral normal alar rim or the ideal, a template of the opposite normal
nostril, and by direct visualization. The position of the ideal alar rim is identi-
fi ed. Incising along the proposed alar margin, the fl ap is completely divided,
separating the proximal covering aspect from its distal lining extension. The
proximal fl ap is completely re-elevated with 2 to 3 mm of subcutaneous fat. The
forehead ‘fl ap’ becomes covering skin of nasal ‘thinness’. The proximal fl ap is
temporarily placed to the side of the operative fi eld.
8. The underlying double layer of soft tissue — residual subcutaneous fat, frontalis,
areolar tissue and a second layer of areolar tissue, frontalis muscle, and subcuta-
neous fat are exposed. This soft tissue overlies the underlying forehead skin
which was folded for lining. It is now integrated into the residual normal lining
and dependent on adjacent intact lining, rather than the fl ap’s pedicle, for blood
supply. This excess soft tissue is excised. As the excess is trimmed, the newly
transferred folded forehead skin is visualized. It is thin, supple, highly vascular,
and approximately equal in thickness to the normal. It is diffi cult to distinguish
from normal nasal lining and bleeds freely.
9. Unscarred, the reconstructed lining is now shaped, supported and braced
against the future contraction of wound healing with delayed primary support
grafts. Individual cartilage grafts are placed to recreate the required subunit
support and shape.
10. The thin, supple, unscarred skin of the proximal fl ap is returned to the recipient
site. It covers the underlying fabrication of primary and delayed primary
cartilage grafts and reconstructed lining.
11. At the third stage, 3 to 4 weeks later, (6 to 8 weeks after beginning the nasal
repair), the pedicle is divided.
The Menick Modifi ed Folded Flap for Nasal Lining

418
Chapter • 18 • Restoring Nasal Lining — the Folded Forehead Flap for Lining; the Menick Modifi ed Method
A
B
C
In Figure 18–1, a large full-thickness defect is present within the right ala and
sidewall.
The ala will be repaired as a subunit. Residual skin at the alar base is discarded.
Figure 18–1

419
Exact templates of the cover and lining defects are positioned above the right supra-
trochlear vessels.
The lining pattern is designed as an extension of the forehead fl ap with a few milli-
meters between templates to permit easing folding. Because the vascularity of a full-
thickness fl ap is so abundant, the junction between the lining and cover replacements
can be narrowed to fi t the defect.
As illustrated in Figure 18–2, the distal extension is turned in to line the defect and
fi xed with fi ne absorbable suture. The more proximal fl ap is folded back onto itself for
cover. No cartilage is placed. The astute observer will notice that the author swung the
fl ap laterally – in the wrong direction!
A
B
C
Figure 18–2
The Menick Modifi ed Folded Flap for Nasal Lining

420
Chapter • 18 • Restoring Nasal Lining — the Folded Forehead Flap for Lining; the Menick Modifi ed Method
Figure 18–2, Continued
D
E
Lining
Full thickness forehead flap
folded for both cover and lining
Future rim
at hinge
Lining
Cover
L
C
Hinge area
Cover

421
The second stage was delayed due to unrelated medical illness (Figure 18–3). Fortu-
nately, fi brosis is not initiated in a forehead fl ap until the frontalis is excised. Four
months later, the fl ap tissues were soft and pliable. A new defect is present in the
inferior forehead after a Mohs excision of a new cancer in the interval.
Figure 18–3
Figure 18–4
A
B
The Menick Modifi ed Folded Flap for Nasal Lining