Operative Technique in Plastic Surgery – Kevin C.Chung

Preoperative Planning
■ In the senior author’s practice, nasal banner and bilobed flaps and nasolabial
flaps are most commonly performed under local anesthesia. Patient preference
should be considered regarding the method of anesthesia.
■ Assess the mobility and laxity of the skin surrounding the defect. Cranial nasal
skin is thinner and more mobile than the caudal skin and must be considered
when planning flap choice and orientation.
■ With proper flap planning of nasolabial flaps, scars will recreate the nasolabial
crease.
■ The alar facial sulcus is a crucial facial aesthetic boundary representing the
convexity between the nose, cheek, and upper lip.
■ Preservation of this boundary is of critical importance in flap design and
should be a primary focus during initial nasolabial flap planning.
■ Secondary revision of this region should be avoided as recreation of this
convexity is challenging.1
Positioning
■ The patient is positioned supine on the operative table with their head turned
to the contralateral side from the defect. Some reverse Trendelenburg with the
neck in slight extension can be useful to decrease venous bleeding.
■ The entire midface, at minimum, is prepped into the field to assess symmetry
intraoperatively.
Approach
■ Banner and bilobed flaps
■ The choice between banner and bilobed flaps is mainly dependent on defect
size and location.
• Smaller defects of the upper nasal sidewall and dorsum (0.5–1.0 cm
diameter) are typically more amenable to banner flap closure. Donor-site
scars are minimal, and medial canthus distortion is avoided. Banner flaps for
nasal tip reconstruction often result in mismatched skin thickness resulting
in unnatural topography. Larger banner flaps involve wider dissections and
undermining, resulting in nasal distortion and significant standing cutaneous
deformity at the pivot point.
• Although bilobed flaps require a more extensive scar pattern, the
geometrically precise design recruits mobile skin from the mid-dorsum and

sidewall to enable greater flap rotation. Better skin thickness match with less
nasal contour distortion and standing cutaneous deformity is achieved at the
pivot point. They are more useful for larger defects (1.0–1.5 cm diameter),
particularly on the central or lateral nasal tip, ala, and caudal sidewall.
Defects on the upper half of the nose are typically not suited for bilobed
reconstruction due to medial canthus distortion.
■ Banner and bilobed flaps include skin, subcutaneous fat, and nasalis muscle
elevated in the areolar tissue plane directly over the perichondrium (if flap is
raised laterally over cartilage) or periosteum (if raised over the nasal bones).
Including the nasalis makes both banner and bilobed flaps myocutaneous,
adding reliable vascularity.
■ Cutaneous nasal defects larger than 1.5 to 2 cm are best reconstructed with
other modalities (forehead flap, dorsonasal flap, or nasolabial flap) as larger
banner or bilobed flaps often leave scars that violate multiple aesthetic
subunits and can result in nasal contour distortion.
■ Nasolabial flaps
■ Depending on the size and location of the defect, decisions must be made
regarding plane of flap elevation (cutaneous, subcutaneous, or fascial) and
need for cartilaginous support for the nasal alae.1
• These flaps can be elevated as peninsular flaps in the cutaneous plane or
island flaps when elevated in the subcutaneous plane.
• We prefer elevation in the subcutaneous or fascial planes, taking advantage
of the rich network of perforating vessels from the facial and angular artery
in this area.
T E C H N I Q U E S
■ Banner Flap
■ The defect is outlined, with additional areas of excision determined in order
to place scars along the borders of aesthetic subunits.
■ Most often, the inferior border of the anticipated banner flap is marked
tangential to the superior border of the defect and oriented in a horizontal
fashion across the dorsum of the nose.
■ The distance between a and c determines flap base width and can be

designed 1 to 2 mm smaller than the diameter of the defect (TECH FIG 1).
■ Point b represents the tip of the flap, and when possible, this landmark is
placed along a subunit border to help hide the donor-site scar.
■ The length of raised tissue (ab) is longer than the defect size, making the flap
a long and thin triangle, facilitating easy and primary closure of the donor
site.
■ After flap design is complete, dilute 0.5% lidocaine with 1:200 000
epinephrine is infiltrated in the subcutaneous plane.
■ The flap is then raised in the areolar plane between the nasalis muscle and
perichondrium/periosteum.
■ The skin surrounding the flap and defect is undermined in the same areolar
plane as the flap to facilitate tension-free closure.
■ The flap donor site is closed first with 6-0 nylon, followed by flap
transposition into the defect.
■ The standing cutaneous deformity at the pivot point is assessed and
removed, typically with a small Burrow triangle excised at point a to
facilitate closure and prevent contour deformity.
■ The flap is then trimmed to fit the defect precisely and inset with interrupted
6-0 nylon sutures.
■ A thin layer of bacitracin is applied to the incisions twice daily until sutures
are removed 5 to 7 days postoperatively.
■ When sutures are removed, Steri-Strips can be applied for an additional
week of support.
TECH FIG 1 • A. The flap is marked adjacent to the
defect (a). The distance between a and c determines
flap width or base and is made slightly smaller than

the diameter of the defect as the defect can be made
smaller during closure. Point b represents the tip of
the flap, and when possible, this landmark is placed in
the alar crease to help hide the donor-site scar. The
length of raised tissue (ab) is longer than the defect
size, making the flap (x) a long and thin triangle (b),
facilitating easy and primary closure of the donor site.
B. Flap x is then raised in the subnasalis plane and
rotated into the defect and trimmed appropriately. C. A
small Burow triangle can be excised at point a, the
pivot point, to facilitate closure.
■ Bilobed Flap
■ Although the original bilobed flap was designed to rotate tissue 180 degrees
into a defect, this design created a large dog-ear at the point of rotation.
■ Zitelli’s modification of limiting total flap rotation to no more than 90 to 110
degrees decreases dog-ear formation and the risk of pincushioning.
■ The flap consists of two lobes, a and b, which are used to cover the defect
and close the donor site, respectively; a is the exact width of the defect, while
b can be slightly narrower as tissue from the more proximal nose is more
mobile and pliable.
■ The height of the second lobe is approximately 1.5 to 2.0 cm greater than
the height of the first lobe.
■ Markings and preoperative planning are paramount in technical execution
and postoperative results.
■ The planned defect is first marked and typically made circular in shape.
■ The flap is designed with a pivot point located at a distance equal to the
defect radius away from the defect margin. Pivot points farther away from
the defect result in larger flaps, which can push each lobe off the nose,
distorting either the eyelid or cheek.
■ When possible, a laterally based flap design is preferred due to improved
vascularity and avoids scars over the nasal dorsum.
■ We suggest using two concentric circles that share the same pivot point to
aid in marking: the larger outer circle has a radius of three times the defect’s

radius, whereas the smaller inner circle has a radius twice the length of the
defect’s (TECH FIG 2A).
■ Premade bilobed flap templates of different sizes can be printed to provide
reliable, easy, and fast bilobed flap design.
■ A template of the defect is then made and placed just inside the
circumference of the outer circle, adjacent to the defect, making lobe a.
■ Lobe b is triangular in shape, adjacent to lobe a, and the farthest away from
the defect; the base of this triangle is along the outside of the inner circle
making it one defect’s radius away from the circular defect.
■ Lobe a can be curved slightly away from the defect, which includes a small
Burrow triangle in its design, preventing dog-ear formation at the pivot point.
■ After flap design is complete, dilute 0.5% lidocaine with 1:200 000
epinephrine is infiltrated in the subcutaneous plane.
■ Incisions are made along the markings, and the flap is elevated in the areolar
plane directly above the perichondrium or periosteum, always including the
nasalis muscle to improve flap vasculature and maintain uniform thickness
with the defect.
■ Undermining extends beyond the base and pivot point of the flap to
improve mobility.
■ The skin around the flap and the defect is also undermined in the same
areolar plane to facilitate tension-free closure.
■ Inset begins with primary closure of the secondary donor site.
■ Lobe a is then rotated 45 to 50 degrees into the defect and inset (TECH FIG
2B–E).
■ The standing cutaneous deformity at the pivot point is excised and closed.
■ Finally, the triangular lobe b is rotated into the primary donor site, trimmed
to fit, and inset. Skin incisions are all closed with 6-0 interrupted nylon
sutures.
■ A thin layer of bacitracin is applied to the incisions twice daily until sutures
are removed 5 to 7 days postoperatively.
■ When sutures are removed, Steri-Strips can be applied for an additional
week of support.

TECH FIG 2 • A. Using two concentric circles that
share the same pivot point aids in marking: the larger
outer circle has a radius of three times the defect’s
radius, and the smaller circle’s center is the defect’s
diameter away from the same shared pivot point (PP).
B. The flap is undermined widely in the submuscular
plane, beyond the base and pivot point of the flap,
avoiding violation of neighboring aesthetic subunits
when possible. Lobe a is then rotated 45 to 50
degrees into the defect, while the triangular lobe (b) is
rotated into the primary donor site. Intraoperative

photographs show markings for a laterally based
bilobed flap for an alar defect (C) that is raised in the
subnasalis plane (D) and inset without tension or
distortion of the nasal subunit (D).
■ Superiorly Based Single-Stage Nasolabial
Advancement Flap
■ The defect is outlined, with additional areas of excision determined in order
to place scars along the borders of aesthetic subunits.
■ The flap is designed beginning at the medial portion of the lateral aspect of
the wound.
■ A line is drawn running parallel to the nasolabial crease and should
encompass a width equal to that of the wound.
■ The lateral aspect of the flap should stop at the level equal to the superior
extent of the wound.
■ A 30-degree Burow triangle should be excised superior to the wound to
prevent dog-ear formation (TECH FIG 3A).
■ After completion of the flap design, dilute 0.5% lidocaine with 1:200 000
epinephrine is infiltrated in the subcutaneous plane.
■ A no. 15 blade is used to complete the drawn incisions into the subcutaneous
tissue (TECH FIG 3B).
■ Using sharp dissection, the entire flap is elevated in a subcutaneous plane.
The flap should be widely undermined in order to prevent a trapdoor
deformity.
■ The superiorly based Burow triangle is excised in a subcutaneous plane.
■ After obtaining hemostasis, the flap inset begins by placement of buried
deep dermal 5-0 PDS sutures. The first suture approximates the cheek skin to
the periosteum in the nasofacial sulcus. The nasolabial crease is then reset by
approximating the most superolateral aspect of the donor wound to the
superior aspect of the alar crease.
■ The flap is then thinned for flap concavity after final inset.
■ The alar groove is recreated by placement of a buried deep dermal 5-0 PDS
suture from the central portion of the flap to the center of the alar crease.
■ The distal portion of the flap is then tailored to fit the contour of the defect

(TECH FIG 3C,D) with approximately 5 mm of overhang beyond the ala.
■ The distal end of the flap is not inset into the defect; rather it is left open to
self-tubularize around the inferior margin of the alar rim as it heals.
■ The remaining incisions are closed in standard layered fashion. The author
prefers deep dermal Monocryl sutures followed by a running nonabsorbable
stitch.
TECH FIG 3 • A,B. Planned incisions for single-stage
advancement nasolabial flap. C. Nasolabial flap after it
has been undermined and brought into the defect. The
distal aspect of the flap is tailored to fit the defect
contour (dashed line) but left approximately 5 mm
longer than the defect and left open to allow self-
tubularization around the inferior margin of the ala as

it heals. The flap will be trimmed along the dashed
line, and the triangular portion of transposed soft
tissue will be discarded. D. The flap is partially inset
by Prolene suture. The incision line along the
nasolabial incision is closed as well as the lateral
aspect of the portion of the flap filling the defect.
■ Two-Stage Interpolated Nasolabial Flap
■ For subtotal nasal sidewall or alar defects, a template of the defect should be
made using a pliable material such as foil.
■ If the entire nasal ala will be reconstructed, an exact template of the
subunit should be made from the contralateral, normal side of the nose.
■ The template is then reversed and placed along the nasolabial fold at a level
superior to a horizontal line drawn through the ipsilateral oral commissure.
■ The medial border of the template should reside in the nasolabial crease,
ensuring final scar closure will lie along the nasolabial crease (TECH FIG
4A).
■ An extra 1 mm of donor margin should be included to compensate for
eventual flap contraction.
■ Donor-site closure is facilitated by excision of a triangular dog-ear. The
medial aspect of the flap should extend distally directly along the nasolabial
crease ensuring donor-site scar camouflage.
■ After completion of the flap design, dilute 0.5% lidocaine with 1:200 000
epinephrine is infiltrated in the subcutaneous plane.
■ A no. 15 blade is used to complete the drawn incisions into subcutaneous
tissue.
■ Using sharp dissection, the entire flap is elevated in a fascial plane (TECH
FIG 4B,C). The flap and, if possible, the recipient area should be widely
undermined to prevent a trapdoor deformity.
■ The proximal skin portion of the flap can be narrowed to allow for
transposition, but care should be taken to encompass a broad subcutaneous
flap base to preserve perforating blood supply.
■ Subcutaneous fibrous bands can be carefully taken down as needed to afford
adequate transposition.

■ After hemostasis is achieved, flap inset begins (TECH FIG 4D). The most
distal aspect of the flap is inset in a single-layer closure with fine,
nonabsorbable, simple interrupted sutures.

TECH FIG 4 • A. Distal sidewall and superior alar
defect with preoperative markings illustrating adjacent
nasal subunits, proposed flap with triangular dog-ear
excision placed along nasolabial fold, and arterial
supply. Planned incisions are made (B), and the flap is
sharply elevated in the fascial plane and advanced
into the defect (C). D. The flap is then inset into the
defect, with the distal aspect excised as tolerated to
allow for primary closure of the donor site along the
nasolabial fold. Three weeks after advancement, the
patient returns (E), and the flap is debulked and inset
for better contour (F). Pedicle division was not
required in this case due to favorable orientation.
■ Wide undermining of the donor site allows for tension-free closure within
the nasolabial crease after excising the dog-ear at the most distal component
of the donor site. The donor site is closed using a fine, nonabsorbable,
running suture.
■ After 3 weeks, the patient is brought back for pedicle division and flap
debulking/inset (TECH FIG 4E,F).
■ First, the pedicle is sharply excised in an elliptical manner using a no. 15
blade, and the donor site is closed primarily. The author prefers this
technique rather than proximal pedicle inset as it leaves the patient with a
linear rather than V-shaped proximal end of the donor-site incision.
■ The flap is then conservatively trimmed, and final flap inset is completed
using fine, nonabsorbable, simple interrupted sutures.
PEARLS AND PITFALLS
Incision
placement
■ Dog-ears do not settle. The flap should be completely flat at the
time of surgery unless there is concern for flap viability.
Flap planning
■ The choice between banner and bilobed flaps is dictated by size
and location. Banner flaps are best suited for more cranial nasal

defects under 1.0 cm. Bilobed flaps work well for caudal defects
up to 1.5 cm.
■ Banner flaps crossing the midline of the nasal dorsum result in
bilateral distortions that are symmetric and less obvious.
■ When truly unilateral, banner flaps may distort alar anatomy,
possible narrowing the vestibule.
■ Both banner and bilobed flaps should be left completely on the
nose because larger flaps can distort eyelid, cheek, and lip
aesthetics.
■ The diameter of wound suitable for nasolabial flap coverage is
usually less than 2.5 cm; however, this is ultimately determined by
the extent of cheek laxity.
■ The convexity of the alar fascial sulcus is of particular importance
when considering facial aesthetic boundaries. If the flap trajectory
will cross over this region, a two-staged interpolated flap must be
used. Advancement flaps crossing the alar fascial sulcus will blunt
the convexity, and this deformity is very difficult to reconstruct.
Flap
limitations
■ The nasolabial flap is most suitable for reconstruction of nasal alar
and caudal nasal sidewall defects. Do not attempt to reconstruct
the nasal tip with nasolabial flap. Such attempts are often
complicated by tip necrosis and extensive trapdoor deformities.
Dermabrasion
■ Postoperative dermabrasion can even out small irregularities at
suture lines and improve scar appearance.
Skin cancer
■ Consider delaying the reconstruction until the margins of resection
are proven clear by histological analysis.
POSTOPERATIVE CARE
■ Patients should rest with their head elevated for the first few days
postoperatively.
■ All facial skin sutures should be removed 5 days postoperatively.
■ Drains should be removed 24 to 48 hours postoperatively.
■ Postoperative antibiotic coverage is not routinely used
OUTCOMES
■ In a series of 70 flaps, Elliott et al. reported only one partial flap loss, salvaged
by a small revision.3
■ Zitelli et al. found excellent color and texture match in all 20 patients treated
with nasal bilobed flaps; the only complication was superficial epidermal
necrosis in two patients.4

■ Dog-ears, pincushioning, and donor-site concavity are the main contributors to
suboptimal aesthetic outcomes.
■ Nasolabial flaps provide excellent reconstruction options of the nasal ala and
caudal nasal sidewall. The skin and subcutaneous tissue of the nasolabial fold
provide a suitable color and texture match with the ability to camouflage scars
in facial aesthetic boundaries. Proper patient selection, appropriate flap design,
gentle tissue handling, and hemostasis minimize complication rates.5,6
■ For defects involving more than half of the alar subunit, a two-staged,
interpolated nasolabial flap can provide results close to patient’s normal. Full
subunit reconstruction allows for camouflage of scars at subunit junctions.7
■ A drawback of the nasolabial flap is that, in some instances, it requires a two-
staged operation. Appropriate patient selection cannot be overstated.
■ Need for revisional surgery is rare in the senior author’s practice but should be
discussed with the patient before the initial operation. Dog-ears should be
excised at the time of initial operation unless there is concern for flap viability.
If this is the case, it is appropriate to come back at a later date for dog-ear
excision. Defects that violate the alar groove in certain instances will require a
secondary operation for recreation of the alar crease.
COMPLICATIONS
■ Flap necrosis
■ Contour deformities, dog ears, pincushioning, and scarring
■ Donor-site concavity
■ Hematoma
■ Infection
REFERENCES
1. Masson JK, Mendelson BC. The banner flap. Am J Surg. 1977;134:419.
2. McGregor JC, Soutar DS. A critical assessment of the bilobed flap. Br J Plast
Surg. 1981;34:197.
3. Elliott RA Jr. Rotation flaps of the nose. Plast Reconstr Surg. 1969;44:147.
4. Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol.
1989;125:957.
5. Fazio MJ, Zitelli JA. The single-stage nasolabial flap. Oper Tech Plast
Reconstr Surg. 1998;5:50-58.
6. Rubin LR, Mishriki Y, Lee G. Anatomy of the nasolabial fold: the keystone of
the smiling mechanism. Plast Reconst Surg. 1989;83(1):1-10.

7. Menick FJ. The two-stage nasolabial flap for subunit reconstruction of the ala.
Oper Tech Plast Reconstr Surg. 1998;5:59-64.

34
CHAPTER
Nasal Reconstruction With
Paramedian Forehead Flap
Robert D. Wallace and Petros Konofaos
DEFINITION
■ Nasal defects can be caused by trauma (including burns) and the sequela of
skin cancer treatment by excision or radiation. Nasal defects can be partial or
through and through involving all the three layers of the nose.
■ Nasal reconstruction involves the use of autologous tissues to repair nasal
defects.
■ All of the affected or missing parts must be replaced to achieve both an
aesthetic (normal-looking nose) and a functional (easy breathing)
reconstruction.
■ The paramedian forehead flap (PMFF) is an interpolated axial flap based
primarily off the supratrochlear neurovascular system and is well suited for
reconstructing complex defects of the nose.
■ This flap produces an excellent tissue color and texture match for nasal
reconstruction.
ANATOMY
Nose
■ The nose consists of a pair of nasal bones that extend from the frontal bone
and caudally fuse with the dorsal septum forming a support structure that
extends along the length of the nasal dorsum (FIG 1A).
■ The caudal aspect of the nasal bones overlaps the cephalic portion of the
upper lateral cartilages for a distance of 2 to 4 mm.
■ The upper lateral cartilages constitute the distal nasal sidewalls and extend
toward the tip of the nose (FIG 1B).

■ At their caudal free edge, they are overlapped by the cephalic portions of the
lower lateral cartilages.
■ The lower lateral cartilages provide the structural support to the soft tissues
of the lower third of the nose.
■ The nasal septum is composed of three structures: the perpendicular plate of
the ethmoid posteriorly and cephalically, the vomer posteriorly and caudally,
and the quadrangular septum anteriorly (see FIG 1A).
■ The septum functions as a support structure for the midportion of the nose,
and it also constitutes the medial component of the internal nasal valve.
■ The blood supply to the dorsal nose is derived from the dorsal nasal artery and
the anterior ethmoidal artery (FIG 1C).
■ The lateral nasal artery, branch of the angular artery, supplies the nasal
sidewalls and the caudal nasal dorsum and tip. The columellar branches of the
superior labial artery with the distal branches of the lateral nasal artery supply
the nasal tip from below.
■ The blood supply to the septum comes from the anterior and posterior
ethmoidal arteries, the sphenopalatine artery, and the posterior septal artery.
■ The sensory innervation to the nose is derived from the ophthalmic (V1)
(upper half of the nose) and the maxillary (V2) (lower half of the nose)
divisions of the cranial nerve V. The motor innervation is from the facial nerve
(VII).
FIG 1 • A–C. Anatomy of the nose.

■ There are three nasal vaults:
■ The bony vault consists of the paired nasal bones and the ascending frontal
process of the maxilla.
■ The upper cartilaginous vault is outlined by the paired upper lateral
cartilages.
■ The lower cartilaginous vault is made of the lower lateral cartilages.
■ The skin envelope of the upper two-thirds of the nose consists of thin, loose,
and mobile skin with few sebaceous glands.
■ The skin of the lower third of the nose is thick and less mobile, with aberrant
sebaceous glands.
Paramedian Forehead Flap
■ The forehead provides a source of skin with an excellent color and texture
match with nasal skin.
■ The PMFF is an axial pattern interpolated flap that is based on the ipsilateral
or contralateral supratrochlear neurovascular system to exit the orbit

approximately 1.7 to 2.2 cm lateral to the midline, in a vertical vector, passing
under orbicularis oculi and above corrugator supercilii muscles (FIG 2).
■ The artery, 1 cm above the brow, runs in the submuscular plane, under the
frontalis, to a more superficial, subcutaneous position at the middle of the
forehead.
■ The PMFF consists of frontalis muscle, subcutaneous fat, and skin, except its
distal portion, in which the majority of subcutaneous fat and the frontalis are
removed.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ During the process of taking the patient’s medical and surgical history,
emphasis should be put on the following:
■ Case of the nasal injury, disease remission, or cancer clearance
■ Tobacco and alcohol use
■ Previous surgeries on the nose, midface, and forehead regions
FIG 2 • Design of paramedian forehead flap. M, medial
side of the flap; L, lateral side of the defect; A, ala; S,
skin excess.

■ History of radiation therapy and/or chemotherapy
■ General health status of the patient and more specifically the existence of
conditions affecting wound healing and flap viability
■ Patient’s ethnicity
■ Active drug use
■ Physical examination
■ The skin of the midface and the forehead regions is inspected for scarring and
previous incision sites.
■ The patency of the nasal airway should be evaluated for constrictions and/or
bulky obstructing tissue, for lateral nasal wall collapse, or external nasal valve
deficiency.
■ Moreover, the nose and the forehead area should be inspected for variations
from normal anatomical topography.
■ Evaluation of the primary defect includes1
• Wound dimensions, shape, and location
• Identification of nasal and/or facial subunits involved
• Wound inspection for infection, constrictions, and other deformities
• Understanding the defect in terms of tissues involved, as complex nasal
defects often involve loss of lining, support, and skin cover
■ Identification of the location of the supratrochlear artery can be achieved
through palpation and/or using a handheld Doppler.
■ Preoperative photography is essential to document the defect, allow outcome
review and comparison, and educate the patient regarding the indicated
surgical treatment.
IMAGING
■ No specific radiographic imaging studies are required.
■ Facial radiograph, computed tomography, or magnetic resonance imaging is
occasionally employed in cancer-related cases with high risk of recurrence or
to clarify bony and soft tissue injury of the midface region.
SURGICAL MANAGEMENT
■ Immediate nasal reconstruction after skin tumor extirpation is safe in selected
patients.
■ Reconstruction is delayed when the histologic margins are questionable, the
tumor histology is aggressive, in case of perineural or deep bony invasion,
and when radiotherapy is to be given.

■ Factors governing the choice of nasal reconstruction include donor-site
morbidity, facial scarring, and the complications associated with borderline
vascularity.
■ Function and appearance were considered of secondary importance. On the
other hand, modern nasal reconstruction emphasizes the restoration of a
normal appearance and function, not on simply obtaining a healed wound.
■ Millard envisioned facial landmarks as “units” and suggested to replace them
in their entirety with tissue of similar color and texture to avoid a patchlike
repair.
■ Burget and Menick2 analyzed the nose as a facial unit with subunits, based on
the skin quality, border outline, and 3-D contour of each region (FIG 3).
■ They also introduced the nasal subunit principle, which holds that, if the defect
is greater than 50% of the subunits, it is better to discard adjacent normal tissue
within the subunit and resurface the entire subunit rather than merely “patching
the hole.” Thus, depending on the extent of the defect, wounds should be
altered in size, configuration, and depth to reconstruct an entire unit.
■ The subunit principle finds its ideal application for defects of the tip and alar
regions because these subunits are convex and can lead to a trapdoor effect
following flap inset and healing, thereby augmenting the effect of recreating
the convex shape of the subunit.
■ For defects of the nasal dorsum and sidewalls, the subunit principle is less
applicable, because these relatively flat subunits blend indistinctly.
■ The principles of ideal nasal reconstruction include
■ The exact replacement of missing tissues in dimension, thickness, and outline
■ The use of the contralateral subunit as a template for reconstruction
■ The establishment of a support framework with primary and delayed primary
cartilage and bone grafts
■ Flap edges blended to the recipient site

FIG 3 • Aesthetic subunits of the nose.
■ Marginal scars braced by cartilage grafts
■ Detailed subcutaneous sculpture
■ It is imperative to educate the patient and outline the necessary steps that will
be required to repair the defect. Moreover, the patient’s preferences and needs
must be considered by the surgeon at the planning of the indicated
reconstruction.
Preoperative Planning
■ Preoperative planning should be guided by the principles of aesthetic regional
unit reconstruction: alter the wound in size, outline, depth, or position, if
helpful, to improve the final result. After defining the defect by means of
location and missing layers, the reconstruction can be broken down into
component parts, with each part addressed in turn.
■ Successful reconstruction is composed of thin, conforming cover that matches
nasal skin in color and texture; thin, vascular, and supple lining that does not
stuff the airway; and a hard tissue framework to support, shape, and brace soft
tissue against gravity, tension, and scar contraction.
■ When designing the selected flap, it is important to avoid either distorting

adjacent structures or making the flap too small. When substantial amounts of
all three layers are lacking, however, the reconstruction becomes more
complex and less predictable.
■ The PMFF is the mainstay of reconstruction for a wide variety of nasal
defects.
■ For subtotal or total nasal defects, a three-stage full-thickness PMFF (with an
extension to supply missing lining or combined with a septal mucosal flap)
and septal or ear support grafts are used.
■ The two-stage PMFF is best suited to resurface small defects that do not
require contour recreation, complex support grafts, or lining replacement. All
stages are performed under general anesthesia.
■ If missing, the nasal midlayer support framework must be replaced, to prevent
nose collapse.
■ The support grafts can be placed primarily if vascularized lining remains or is
restored with intranasal lining flaps.
■ Otherwise, the structural grafts are placed during the second stage of
reconstruction with PMFF.
■ Sources for support graft for cartilage can be septal or ear cartilage and for
bone calvarial or rib bone grafts.
■ Whereas septal cartilage is especially useful as a single or layered onlay
dorsal graft, a tip graft, a sidewall brace, or a columellar strut, the ear remains
the workhorse of tip and alar repair.
■ If deficits of the internal lining cannot be closed primarily, there are several
options for reconstituting it.
■ If left unrepaired, the area will heal by secondary intention with significant
wound contracture, alar distortion, and nasal obstruction.
■ Punctate defects can be closed primarily, whereas an independent flap is
required to repair larger defects.
■ Most commonly used options include the folded PMFF, the ipsilateral septal
mucosal flap, and a full-thickness skin graft (in combination with PMFF).
■ In cases in which ischemic tissue is identified, prior to reconstruction, the
wound should be debrided after it demarcates itself.
■ A contaminated or infected wound should be debrided and controlled with
antibiotics prior to reconstruction.
■ Significant edema and wound tension are given time to resolve.
■ In cases in which the defect extends/includes to the lip and/or cheek units,

reconstruction of these areas must be established, prior to nasal reconstruction.
■ Options include cheek advancement flap with/without a nasolabial extension
to resurface the cheek and/or lip, an Abbe flap (if the full thickness of the
upper lip is absent), or a free flap depending on the dimensions and/or depth
of the defect.
Positioning
■ The patient is placed supine on the operating room table in 20 to 30 degrees of
a reverse Trendelenburg position.
■ This position has the advantage of decreasing intraoperative blood loss by
eliminating venous pooling and flap congestion.
■ Bland ophthalmic ointment is applied to the globe. The patient’s eyes are
closed and protected with Tegaderm.
■ The full face and scalp, from the midvertex to the submental area, are prepared
with a sterilization solution of the surgeon’s choice.
■ A sterile head drape is placed, and full-body draping is completed in the
usual sterile fashion.
■ After induction of general endotracheal anesthesia, the operating room table is
rotated to position the anesthesiologist at the patient’s right hip.
■ Pressure points on upper extremities are padded, and a pillow is placed under
the patient’s knees.
■ Alternating pressure devices are applied to the lower legs.
T E C H N I Q U E S
■ Markings and Templating
■ Using a marking pen, the hairline, frown lines, subunits of the nose and lip,
old scars, grafts, flaps, the location of planned vascular pedicles, areas of soft
tissue excess or deficiency, and facial landmarks are marked during all stages
(TECH FIG 1A,B).
■ The path of the supratrochlear artery can be mapped out using a Doppler
probe, but the author has not found this to be necessary.
■ The base of the pedicle is usually centered over the supratrochlear artery
on the same side, which corresponds to the medial border of the eyebrow in

the majority of patients.
■ The pedicle portion of the PMFF can be as narrow as 1.5 cm, which allows
for an easier primary closure over the inferior portion of the flap (TECH
FIG 1C).
■ Templates, based on the contralateral normal, are especially helpful to
determine the dimension, outline, and contour required to restore the defect.

TECH FIG 1 • Lateral (A) and anterior (B) view of
preoperative markings of the nasal aesthetic subunits.
C. The pedicle portion of the paramedian forehead
flap can be as narrow as 1.5 cm, which allows for an
easier primary closure over the inferior portion of the
flap. D. Using the foil of a suture pack, a template of
the contralateral normal side can be created with the
silver side exposed. E. The template is flipped and
oriented properly into the defect with the colored
surface outward. F. The length of the pedicle is
measured by a length of suture/gauze extending from
the distal end of the positioned template to the level of
the medial eyebrow.
■ Using the foil of a suture pack, a template of the contralateral normal side
can be created with the silver side exposed (TECH FIG 1D).
■ Then, the template is flipped and oriented properly into the defect with its
colored surface outward (see TECH FIG 1E).
■ The foil-based templates can be preserved, resterilized, and reused during

later operations.
■ The template is used to design the flap on the forehead skin.
■ The upper border of the template is positioned at the frontal hairline unless
the patient has a receding hairline or frontal balding.
■ If the PMFF is used for covering the lining defect, the lining template is
positioned as a distal extension of the covering flap with a few millimeters
of excess skin between the cover and lining flaps to ease its folding.
■ If necessary, the lining extension can carry a few hair follicles (see FIG 2).
■ The length of the pedicle is measured by a length of suture/gauze extending
from the distal end of the positioned template to the level of the medial
eyebrow.
■ Then, by stabilizing the suture/gauze at the eyebrow, it is rotated 180
degrees in the coronal plane toward the midline to the most distal recipient
site on the nose.
• This step is vital to determine the exact position of the template on the
forehead.
■ The flap is then precisely outlined on the forehead with a skin marker,
following the exact shape of the template (TECH FIG 1F).
■ Stage 1: Elevation and Placement of the Flap
■ After induction of general anesthesia and once the markings have been
placed, local anesthetic (lidocaine 1% with epinephrine 1:100 000
concentration) is injected around the planned incision lines for hemostasis,
sparing the lower part of the flap and the pedicle.
■ A prophylactic antistaphylococcal antibiotic of the surgeon’s choice is
administered intravenously.
Reconstruction of the Nasal Lining
■ If a patient has a deficit of the internal nasal lining, this is repaired prior to
inset of the PMFF.
■ If the defect cannot be closed primarily, either an ipsilateral septal mucosal
flap3 or a folded PMFF is commonly used.
■ The ipsilateral septal mucosal flap is based on the septal branch of the
superior labial artery.
■ Following injection of the septal mucosa with local anesthetic (lidocaine
1% with epinephrine 1:100 000 concentration), in the subperichondrial

plane along the entire length of the septum, two horizontal incisions
extending from anterior to posterior are made with a scalpel on an extended
handle.
■ Both incisions should extend as far as posterior as possible (around 2 cm
posterior to the bone-cartilage junction of the septum).
■ A posterior vertical incision is then made between the ends of the dorsal
and inferior septal incisions.
■ The flap is dissected in the subperichondrial plane from above downward
toward the floor of the nose and from posterior to anterior.
■ Then, it is rotated laterally and inferiorly to line the vestibule and the
lateral sidewall, with the mucosal surface facing toward the nasal passage,
and is sutured in the defect.
■ The exposed cartilage is left to heal by secondary intention or harvested for
cartilage replacement (TECH FIG 2).
TECH FIG 2 • Repair of the nasal lining. After the
ipsilateral septal mucosal flap is raised, it is rotated
laterally and inferiorly to line the vestibule and the
lateral sidewall.
■ If a folded PMFF is selected for lining reconstruction, the distal lining
extension of the PMFF is folded inward and sutured to the residual mucosal
lining about the margin of the defect with 5-0 Vicryl Rapide interrupted

sutures.
■ No primary cartilage support is placed within the folded flap at this stage.
Ala Cartilage Grafting
■ Following lining reconstruction, the missing framework is substituted by
means of cartilage grafts.
■ For ala cartilage grafting, we use ear concha cartilage through an anterior
incision.
■ The incision lies within the antihelix. It is barely visible and provides
adequate exposure for harvesting the indicated amount of cartilage. In most
cases, the entire concha is removed (TECH FIG 3A,B).
■ The incision is closed with interrupted 5-0 Vicryl Rapide sutures.
■ Quilting sutures approximate the anterior and posterior auricular skin
(TECH FIG 3C).
■ Based on the defect’s size and geometry, the area that will best provide the
appropriate contour and dimension is cut out from the harvested material.
■ The grafts are fixed with interrupted 5-0 chromic sutures to the residual
normal skeleton, to each other, and to the underlying lining (TECH FIG
3D).
Flap Elevation and Donor-Site Closure
■ The PMFF is incised through the skin, subcutaneous tissue, muscle, and
fascia.
■ Elevation of the flap is undertaken with blunt dissection in the subfascial
plane, above periosteum, from superior to inferior fashion.
■ When the corrugator supercilii muscle is encountered, it is dissected from
the underlying periosteum bluntly to allow greater mobility of the pedicle.
■ At this point, the supratrochlear artery may sometimes be visualized on the
deep surface of the frontalis muscle just as it exits over or through the
corrugator supercilii muscle.
■ If the pedicle length is not sufficient, the incision is carried below the level
of the eyebrow. This incision is made through skin and subcutaneous tissues.
■ Then, using blunt dissection, the pedicle is mobilized away from the
medial bony orbit.
■ Following flap elevation, hemostasis along the border of the flap is achieved
with an electrocautery applied judiciously.
■ Donor-site closure is accomplished in layers after undermining, in the

subgaleal plane, of the skin borders up to 1 cm.
■ As the wound edges are advanced, a dog-ear deformity of scalp tissue
occurs at the superior apex of the flap donor-site defect. This is excised
completely by extending an incision sufficiently superiorly in the scalp.
■ The muscle and galea of the forehead are approximated as a single layer with
simple 3-0 Monocryl sutures.
■ The skin incision is repaired with simple sutures of 5-0 or 6-0 nylon. A
drain is not employed.
■ Any gap that cannot be approximated is allowed to heal secondarily, which
takes approximately 6 to 8 weeks.
Defect Preparation
■ Once it is clear that the previously raised PMFF has adequate rotation and
vascularity, the defect is recreated by excising the residual skin (and scar)
within the subunit, only if the defect encompasses more than half of a convex
nasal subunit (the tip or ala).
TECH FIG 3 • Cartilage graft. A. Anterior approach for
ear concha cartilage graft. B. The cartilage graft. C.
The incision is closed with interrupted 5-0 Vicryl
Rapide sutures. Quilting sutures approximate the

anterior and posterior auricular skin. D. The cartilage
graft is fixed with interrupted 5-0 chromic sutures to
the residual normal skeleton.
TECH FIG 4 • A. The paramedian forehead flap is
rotated in the defect. B. Following cauterization along
their entire length of the pedicle to control
postoperative bleeding, the raw surface of the pedicle
is dressed with Xeroform and antibiotic ointment.
■ This does not apply for defects within the dorsal and sidewall subunits.
■ If indicated, the remaining skin of the subunit is removed to the level of the
perichondrium or periosteum.
■ The skin around the nasal defect is undermined below the muscle layer for
1 cm, which helps with flap insetting and prevents trapdoor deformity.
Handling of the Paramedian Forehead Flap Pedicle
■ Thinning of the distal portion of the PMFF, through removal of the muscle
and most of the subcutaneous fat, is important to be sufficiently supple and
thin to conform to the nasal framework and manifest its contour.
■ Further thinning of the PMFF is performed during the second and third
stage of reconstruction.
■ Following thinning, the flap is rotated into the defect and secured in place

with 5-0 nylon interrupted sutures for precise approximation of the skin
edges.
■ The raw borders of the pedicle of the flap are cauterized along their entire
length to control postoperative bleeding, a common occurrence during the
first 12 hours after surgery.
■ Some authors recommend the use of a full-thickness skin graft on the raw
surface of the pedicle to avoid bleeding.
■ We have not found this step necessary and simply treat the raw surface of
the pedicle with Xeroform and antibiotic ointment, thus avoiding the
unnecessary use of a skin graft and the correlated donor-site morbidity
(TECH FIG 4B).
■ Stage 2: Sculpture of the Nasal Repair
■ Three to four weeks after the PMFF transfer into the nasal defect, sculpture
of the nasal repair is performed (TECH FIG 5A).
■ The procedure is performed under general anesthesia to avoid the
distortion created by local anesthesia or the chemical blanching of
epinephrine.
■ Moreover, in cases where the folded PMFF is used, placement of cartilage
grafts are also taken place at this stage.
■ The nasal and regional units, the PMFF border scars, the ideal nostril rim
and nostril aperture, and the excess between the cover and lining flaps are
marked.
■ The ideal outline of the reconstructed ala is determined by remarking the
correct rim position and outline, based on a template of the contralateral
normal (TECH FIG 5B).
■ An incision is made along the margin of right alar rim.
■ The forehead skin is easily elevated, with 2 to 3 mm of subcutaneous fat.
■ Flap elevation varies, depending on the extent of soft tissue excisional
sculpture needed or the need to place additional delayed primary cartilage
grafts.
■ The excess flap between the cover and lining must be eliminated (TECH
FIG 5C).
■ Following creation of an ideal subsurface shape, the forehead skin, of
comparable thickness to the native nasal skin, is returned to the recipient site.

■ The cover flap is secured with a single layer of 5-0 nylon interrupted
sutures.
■ Quilting sutures of 5-0 Vicryl Rapide are placed over the position of the
alar crease in order to define the upper border of the ala (TECH FIG 5D).
TECH FIG 5 • A. Complete epithelialization of the raw
surface of the pedicle is seen 2 weeks after the first

stage of reconstruction without the use of a skin graft.
B. The ideal outline of the reconstructed ala is
determined by remarking the correct rim position and
outline, based on a template of the contralateral
normal. C. Elimination of the excess flap between the
cover and lining. D. After the cover flap is secured with
5-0 nylon interrupted sutures, quilting sutures of 5-0
Vicryl Rapide are placed over the position of the alar
crease in order to define the upper border of the ala.
■ Stage 3: Division of the Pedicle
■ Three to four weeks later (6–8 weeks after flap transfer), the pedicle is
divided.
■ Lidocaine 1% containing epinephrine is injected into the base of the pedicle
and circumferentially around the flap where it attaches to the nose, followed
by the usual sterile preparation and draping.
■ The pedicle is separated with a scalpel at the superior margin of the nasal
defect.
■ An incision is made between the flap and adjacent nasal skin on either side
of the pedicle to release the cephalic portion of the flap from the nose. This
improves nasal contour through thinning and proper trimming and inset of
the flap.
■ The incision is closed with 5-0 nylon interrupted stitches.
■ The remnant of the pedicle is completely excised in a fusiform shape.
■ The defect is closed along the line of the PMFF closure, thus returning the
brow to its anatomic position.
PEARLS AND PITFALLS
Indications
■ Reconstruction of complex post-traumatic and post–tumor exci
nasal deformities
Contraindications
■ Patients with soft tissue loss, prior surgery/trauma, radiation the

at the forehead
■ Patients unwilling or unable to tolerate multiple-stage operation
Planning
■ Paramedian placement of the skin paddle leaves a more
aesthetically pleasing scar and allows the potential of two PMFF
a single patient.
■ The narrow pedicle design provides a greater arc of rotation wi
less chance of kinking of the vascular pedicle.
■ In patients with vascular compromise, such as those with
atherosclerotic disease, diabetes, or long-standing tobacco use,
surgical delay of the PMFF is advised (FIG 4).
FIG 4 • A. Following raising of a paramedian forehead flap in an
active smoker with a nasal defect, the flap showed signs of vascular
compromise. Thus, a surgical delay of the flap was performed. B.
The same flap 3 days later shows complete reversal of the vascular
compromise.
Technique
■ Aggressive thinning of the most distal part of the skin paddle d
to the dermal plexus can be performed during the initial flap
elevation or at an intermediate stage.
■ Lining and structural support need to be addressed for complex
nasal defects at the initial stage of PMMF elevation.
■ Scars are re-excised during pedicle division, and meticulous
approximation of flap edges is essential to restore optimal
appearance.

POSTOPERATIVE CARE
■ Postoperative care consists of cleaning the suture lines with soap and normal
saline and application of antibiotic ointment twice daily for 3 days. Sutures are
removed on the 7th to 10th postoperative day.
■ The patient is advised to avoid excessive sunlight exposure to the forehead and
face region for 6 months to prevent postinflammatory hyperpigmentation of the
scars. Moreover, extremes of heat or cold may cause temporary color changes
in the flap skin at the recipient site and are better avoided for several months.
■ The Xeroform wrap around the raw surface of the pedicle is removed between
the 3rd and 5th postoperative day, and then, it is treated with antibiotic
ointment till complete epithelialization is achieved.
■ The donor site of the PMFF, which cannot be closed primarily, is treated with
Xeroform, antibiotic ointment, and eye patch till the 3rd to 5th postoperative
day.
OUTCOMES
■ Two patient examples are shown in FIG 5.
■ Little et al.4 presented their experience with the use of PMFF in nasal
reconstruction.
■ According to their results, the complication rate was 16.1%. Full-thickness
defects and smoking were significantly associated with major complications.
■ On the other hand, age, vascular disease, or diabetes was not significantly
associated with complications.
■ The authors suggested that for patients most at risk, a three-stage PMFF
should be used for reconstruction.
■ Paddack et al.,5 through a retrospective review study, studied the factors
contributing to treatment failure with the PMFF in nasal reconstruction. Their
study included 82 patients who underwent two-stage PMFF repair.
■ The overall failure rate was 6%.
■ No single comorbidity was noted to have a statistically significant effect on
failure rates, although 83% of failures were observed in smokers.
■ Kendler et al.6 assessed the aesthetic and functional outcomes and
complications of PMFF in elderly patients with nonmelanoma skin cancer.
There were 28 patients included with median age of 81 years (range, 75–95
years).
■ Although there were seven treatment-related complications, the authors

suggested that the PMFF procedure is a safe and low-risk procedure in
patients 75 years of age or older with advanced nasal defects.

FIG 5 • A. This Caucasian male patient had a left ala
defect following Mohs tumor excision. B. Long-term
outcome (3 years) following a two-stage reconstruction
with a PMFF. C. This Caucasian female patient had a

lower half nasal defect—including left ala, tip, and lower
half of the dorsum—following Mohs tumor excision. D.
First stage of reconstruction with a paramedian
forehead flap. The donor site was healed by secondary
intention. E,F. Long-term outcome (1 year) after a three-
stage reconstruction with a PMFF.
■ Rohrich et al.7 performed a retrospective analysis on 1334 patients who
underwent nasal reconstruction. Three- or two-stage reconstruction was
performed in 81% of the cases.
■ The revision rate was 1.2%.
■ The authors suggested the use of axial pattern flaps such as the PMFF for
defects larger than 1.5 to 2 cm in diameter in more than two stages of
reconstruction.
COMPLICATIONS
■ The complication rate for PMFF is low. Hematomas, flap partial or total
compromise, and poor aesthetic outcome are the most common complications.
■ The development of small hematomas under the distal portion of the flap is the
most common complication observed with PMFF. Hematomas develop at the
time of initial flap transfer due to the rich vascularity of the flap, which creates
a tendency for the undersurface of the portion of the flap thinned of its muscle
and subcutaneous fat at the time of transfer to bleed postoperatively.
■ To reduce the development of hematomas, careful hemostasis is needed over
the entire raw undersurface of the thinned portion of the flap.
■ Flap partial or total compromise is mainly due to venous congestion. This is
avoidable in at-risk patients by taking the aforementioned precautions in design
of the flap and use of surgical delay in indicated cases.
■ Other options for salvaging a compromised PMFF include debridement
followed by a second flap or graft.
■ Poor aesthetic outcome include the appearance of the forehead scar, the ill-
defined alar crease, the bulky nostril margin, the short nostril aperture, or an
area of excess tissue.
■ At 4 to 6 months, once wound maturation is complete, the alar crease can be
defined by direct soft tissue excision; a hanging nostril margin trimmed by
rim excision; the nasal aperture enlarged by local soft tissue excision, local

lining redistribution, or a composite skin graft, and the forehead donor scar
can be revised by excision and readvanced, discarding any area of
hypertrophy associated with secondary healing.
REFERENCES
1. Oo KK, Park SS. The midline forehead flap in nasal reconstruction. Facial
Plast Surg Clin North Am. 2011;19(1):141-155.
2. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast
Reconstr Surg. 1985;76(2):239-247.
3. Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty and
blood supply. Plast Reconstr Surg. 1989;84:189-203.
4. Little S, Hughley BB, Park SS. Complications with forehead flaps in nasal
reconstruction. Laryngoscope. 2009;119:1093-1099.
5. Paddack AC, Frank RW, Spencer HJ, et al. Outcomes of paramedian forehead
and nasolabial interpolation flaps in nasal reconstruction. Arch Otolaryngol
Head Neck Surg. 2012;138(4):367-371.
6. Kendler M, Averbeck M, Wetzig T. Reconstruction of nasal defects with
forehead flaps in patients older than 75 years of age. J Eur Acad Dermatol
Venereol. 2014;28(5):662-666.
7. Rohrich RJ, Griffin JR, Ansari M, et al. Nasal reconstruction—beyond
aesthetic subunits: a 15-year review of 1334 cases. Plast Reconstr Surg.
2004;114(6):1405-1416.

35
CHAPTER
Septal Flaps for Nasal
Lining
Jordan D. Frey, John T. Stranix, and Pierre Saadeh
DEFINITION
■ Nasal defects are classified on the anatomical basis of the affected nasal layer:
external nasal cover or skin, bony or cartilaginous nasal support, or internal
nasal lining.
■ Replacement of nasal lining is considered the most imperative and challenging
aspect in all of nasal reconstruction.1
■ Poor nasal lining replacement will lead to internal scarring and contracture
that will compromise the aesthetic and function of native and/or reconstructed
nasal cover and support.
■ Intranasal septal flaps are often favored for nasal lining reconstruction because
they provide thin, reliably vascular tissue upon which cartilaginous support
establishes nasal shape and support.2,3
ANATOMY
■ Intranasal lining transitions from the stratified squamous epithelium of the ala
and columella to the mucoperichondrium of the septum and mucosa of the
nasal vault.4
■ Laterally, internal nasal mucosa is supplied by the facial and angular arteries.
■ Septal mucoperichondrium is supplied by the paired septal branches of the
superior labial arteries and paired anterior ethmoidal arteries5,6 (FIG 1).
■ The septal branches of the superior labial artery arise anteriorly through the
orbicularis oris muscle lateral to the nasal spine at the base of the columella.
■ The anterior ethmoidal vessels arise posteriorly passing below the nasal
bones to supply the dorsal septum.
■ A variety of septal flaps can be designed based on these vascular pedicles to

replace deficient nasal lining.
PATHOGENESIS
■ Nasal lining defects may arise from a variety of mechanisms including
traumatic, oncologic, infectious, autoimmune, iatrogenic, and drug-induced
etiologies.3–5,7
■ Although oncologic resections or traumatic injury can result in more localized
defects, autoimmune and infectious etiologies more often produce pan-mucosal
insult.4
■ Nasal lining deficiencies may occur in isolation or in the context of nasal
support or cover deficiencies, including full-thickness nasal defects.
■ Septal flaps can be utilized for primary nasal lining defects or to cover
secondary defects after other intranasal flaps have been used to provide lining
for the primary defect.
NATURAL HISTORY
■ Significant isolated nasal lining defects eventually result in scar contracture
that can circumferentially destroy the midvault and nasal floor.4
■ This is followed by cartilage and bone necrosis leading to loss of midvault
support, tip rotation, and central facial collapse toward the piriform aperture.4
■ Bony nasal vault collapse is prevented by the strength of the nasal bones.4
■ Ultimately, if external nasal skin becomes devascularized, full-thickness
necrosis can occur.4
■ Therefore, expeditious reconstruction of nasal lining defects, before the onset
of scar contracture, guided by defect etiology, is strongly favored to provide
optimal aesthetic and functional results.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Upon initial presentation, nasal lining defect etiology must be determined.
■ If an etiology is not determined or residual disease is apparent, appropriate
investigative biopsies, cultures, laboratory tests, or referrals should be
arranged.4
■ It is imperative that the inciting etiology of the defect is rendered quiescent
prior to any intervention, lest the ultimate reconstruction be compromised by
ongoing pathology.

FIG 1 • The septal mucoperichondrium is largely
supplied by the paired septal branches of the superior
labial arteries anteriorly and paired anterior ethmoidal
arteries posterodorsally.
■ Possible symptoms of nasal obstruction should be elicited from the patient on
history and examination because septal flaps may further compromise
obstruction.
■ A full extra- and intranasal physical examination should largely focus on
defining the location, size, and extent of the nasal lining defect as well as any
defects in nasal support or cover to guide the determination of the septal flap
required.
■ The subunit principle proposed by Burget and Menick is used to classify
nasal cover defects and guide external nasal reconstruction.8
■ The septal mucoperichondrium and its blood supply should be examined to
ensure its integrity; injury along the nasal spine or posterior septum may
indicate damage to the superior labial or anterior ethmoidal vessels,
respectively.

IMAGING
■ Traditional radiographic imaging is generally not necessary when planning for
nasal lining reconstruction with septal flaps.
■ Meticulous and standardized preoperative patient photography is mandated for
both accurate operative planning and assessment of postoperative results.
DIFFERENTIAL DIAGNOSIS
■ Trauma (facial fractures, foreign body)
■ Oncologic (basal cell carcinoma, squamous cell carcinoma, melanoma,
lymphoma)
■ Infectious disease (syphilis, tuberculosis)
■ Autoimmune disease (Wegener granulomatosis)
■ Iatrogenic injury (septorhinoplasty, endotracheal tube pressure necrosis)
■ Intranasal drug abuse (cocaine)
SURGICAL MANAGEMENT
■ The use of septal flaps for nasal lining in any given defect is based on the size
and location of the defect and the availability of septal mucoperichondrium;
defect etiology and status of nasal cover and support are separate
considerations.
■ When needed, the septum proper may be harvested as graft for nasal support;
care is taken to leave an adequate L strut to prevent dorsal nasal collapse.
Preoperative Planning
■ Preoperatively, patient examination and photography help determine the full
extent of the total nasal defect including the status of the nasal lining to
develop a comprehensive operative plan.
■ Patients are counseled preoperatively that multiple stages are typically
required for complex nasal reconstruction and that the need for minor revisions
postoperatively is likely, regardless of the type of reconstruction being pursued.
■ Preparatory surgery includes debridement of necrotic or infected tissues and/or
release of tethered scars at the time of or before definitive reconstruction.
■ These procedures may also take place at the time of flap delay, prelamination,
or prefabrication per the reconstructive requirements.
Positioning
■ Patients are positioned in the supine position with the neck in slight extension

to facilitate surgical access to the nose; this can be augmented with a shoulder
roll.
■ Slight reverse Trendelenburg can help decrease venous pressure and thereby
bleeding.
■ As required, the ears and/or chest is included in the surgical field to permit
conchal cartilage or rib graft harvest for nasal support.
Approach
■ If not performed in isolation, nasal lining reconstruction should precede
reconstruction of nasal support and external coverage.
■ The nasal lining defect is reincised to establish fresh defect edges and release
any residual scar for accurate estimation of the amount of tissue required for
reconstruction.
■ Local hingeover or vestibular bipedicled flaps with fixed sizes and less donor-
site morbidity are performed first if multiple flaps are required with a septal
flap for nasal lining reconstruction.
■ This allows for the harvest of the smallest possible septal flap that still
provides adequate defect lining.
T E C H N I Q U E S
■ Ipsilateral Mucoperichondrial Septal Flap
■ An ipsilateral mucoperichondrial septal flap is raised based on one of the
paired septal branches of the superior labial artery.
■ This flap can be designed up to 3 cm in width by 3 cm in length and
transposed laterally to provide lining for ipsilateral nasal vestibular and
inferior sidewall defects.
■ Superiorly, the flap can reach the medial canthus and, inferiorly, the nasal
floor.
■ To harvest the flap, an incision is made extending from the anterior area of
the nasal spine upward toward the dorsum in a straight line (TECH FIG 1A).
■ The incision travels posteriorly at a level of 6 to 8 mm below the nasal
dorsum moving parallel to the dorsum and nasal bones after which it is taken
inferiorly at a right angle toward the nasal floor.

■ The incision continues anteriorly from the inferior aspect of the posterior
vertical incision toward the nasal spine, leaving a cuff of tissue surrounding
the pedicle.
■ 10 to 15 mm of cartilaginous L strut is preserved (TECH FIG 1B).
■ The mucoperichondrium is carefully elevated off the septum.
■ The flap is then transposed laterally and sutured to the edges of the defect
without tension (TECH FIG 1C–E).
TECH FIG 1 • A. Creation of an ipsilateral
mucoperichondrial septal flap begins by extending an
incision from the anterior nasal spine upward toward
the dorsum in a straight line; the incision carries
posteriorly moving parallel along the dorsum and
nasal bones before turning 90 degrees to extend

inferiorly to the nasal floor. The incision continues
anteriorly toward the nasal spine, leaving a cuff of
tissue surrounding the pedicle. This flap is supplied by
a septal branch of the superior labial artery. B. Care
must be taken to preserve 10 to 15 mm of
cartilaginous L strut to avoid loss of structural integrity.
C–E. This composite nasal defect required staged
reconstruction. Left nasal lining was reconstructed
with ipsilateral mucoperichondrial septal flap (arrows)
that was elevated off the residual nasal septum
(yellow asterisks) and inset laterally along the defect
edge (green line in E). The nasal dorsum was
reconstructed with a cantilever bone graft (blue
asterisks), and the patient ultimately underwent
external coverage that consisted of a paramedian
forehead flap.
■ Contralateral Mucoperichondrial Septal Flap
■ Contralateral mucoperichondrial septal flaps are utilized for moderately
sized lateral sidewall nasal lining defects of the midvault that cannot be
adequately covered by an ipsilateral septal flap.
■ This flap is based dorsally off one of the paired anterior ethmoidal arteries.
■ A contralateral mucosal flap is first designed with a width equal to the
vertical height of the defect that must be covered; this width may span the
entire dorsum if needed.
■ Two vertical lines approximating the adequate width of the flap are drawn,
extending vertically from the dorsum to the nasal floor.
■ A ventral horizontal line is drawn connecting the vertical lines to complete
flap design; no incision is made along the nasal dorsum.
■ Once the contralateral mucosal flap is designed, a horizontal incision is
made approximately 6 to 8 millimeters from the nasal dorsum on the
ipsilateral mucoperichondrium.
■ The ipsilateral mucosa is raised off the septum, and the septum is harvested

with care taken to leave an adequate L strut and to protect the contralateral
mucoperichondrial flap.
■ The contralateral flap is incised and passed through the slit in the ipsilateral
mucosa after which it is transposed and sutured to the contralateral nasal
lining defect (TECH FIG 2).
■ The ipsilateral nasal bone or middle crura of the lower lateral cartilage may
be resected or transected to facilitate superior or inferior flap transposition,
respectively.
■ The contralateral mucoperichondrial flap may be designed to extend onto the
nasal floor; this will permit the flap to reach the lateral piriform aperture on
the defect side.
■ The ipsilateral septal mucoperichondrium must be preserved to prevent a
significant septal fistula.
TECH FIG 2 • The contralateral mucoperichondrial
septal flap is designed similarly to the ipsilateral septal
flap. A slit is made along the nasal dorsum on the
ipsilateral septal mucosa, which is then carefully lifted
off the septum. The septum is harvested and may be
used for nasal support as required. The contralateral
septal flap may then be incised and transposed

through the slit in the ipsilateral septal mucosa into the
defect. This flap is supplied dorsally by the anterior
ethmoidal artery.
■ Septal Composite Hinge or Pivot Flap for Central
Nasal Lining
■ Cases requiring central nasal lining often coincide with subtotal or total
defects of the nasal soft tissues, anterior septum, and nasal bones.
■ In these circumstances, the total or remaining composite nasal septum can be
elevated based on the bilateral superior labial arteries and “hinged” or
“pivoted” anteriorly to provide both support and lining.
■ The flap is created by making full-thickness incisions through the septum
superiorly at a level approximately 1 centimeter below the dorsum and
inferiorly along the nasal floor.
■ A soft tissue cuff is left surrounding the pedicle in the region of the nasal
spine and upper lip.
■ The superior and inferior cuts are then connected with a posterior vertical cut
(TECH FIG 3).
■ The bilateral mucoperichondrium near the nasal spine is elevated off the
septum, and a small piece of cartilage and bone is resected to facilitate flap
transposition anteriorly.
■ The superior edge of the transposed septum is secured to the remaining
upper lateral cartilages or nasal bones.
■ In total nasal defects with loss of cartilaginous and bony support, bone
grafting or other reconstruction of the nasal process of the frontal bone is
required prior to securing the composite septal flap.
■ Inferiorly based bilateral septal mucoperichondrial flaps can be raised either
immediately or after delay to provide midvault and upper vault nasal lining.
■ In total nasal defects, the septal mucoperichondrium will not reach inferiorly
nor will it reach far enough laterally to completely line the middle and upper
nasal vestibule; additional nasal lining reconstruction is required.

TECH FIG 3 • The septal composite hinge or pivot flap
is created by making full-thickness cuts through the
septum superiorly at a level approximately 1
centimeter below the dorsum and inferiorly along the
nasal floor. A soft tissue cuff is left surrounding the
pedicle similar to the ipsilateral septal flap. The
superior and inferior cuts are then connected with a
posterior vertical cut. Inferiorly based septal
mucoperichondrial flaps can be raised bilaterally to
provide nasal lining.
PEARLS AND PITFALLS
Patient history
■ All patients should be assessed for smoking, which
decreases intranasal septal flaps reliability.
Preoperative
planning
■ Templates of nasal lining defects are useful intraoperatively
after all scarring has been released to help ensure the
adequate septal flap design.