Operative Technique in Plastic Surgery – Kevin C.Chung

■ Depending on the extent of the reconstruction, patients can usually quickly
resume their normal daily activities but should be advised to avoid any
activities that could result in injury to the face; extra care should be taken while
asleep to ensure that inadvertent trauma to the nose does not occur.
■ Smokers must refrain from smoking at least 1 month preoperatively and until
reconstruction is completed.
■ Patients should be reminded of the staged nature of most nasal reconstructions.
OUTCOMES
■ Overall, patient satisfaction with nasal appearance after nasal reconstruction
with septal mucoperichondrial flaps as part of overall nasal reconstruction is
high (greater than 80%).1,4,6,7
■ Rates of objective and subjective nasal obstruction after septal flaps for lining
coverage range from 0% to 31%.1,5,7
■ Isolated nasal lining defects undergoing reconstruction rarely result in
functional nasal compromise.4
■ Short-term postoperative nasal bleeding requiring nasal packing in this patient
population is as high as 66%.5
■ Rates of long-term nasal mucosal crusting and bleeding after nasal lining
reconstruction with septal flaps range from 0% to 36% and from 0% to 6%,
respectively.1,5,7
■ Infection and partial or complete flap necrosis are rare.1,5,7
COMPLICATIONS
■ Short-term complications include nasal bleeding, crusting, and obstruction.3,5
■ Nasal bleeding and crusting may persist long term.3,5,7
■ Persistent iatrogenic septal fistulae may develop after ipsilateral or
contralateral septal flaps; when small, fistulae may cause whistling.1
■ Large septal fistulae from composite septal hinge or pivot flaps are inherent to
flap design and generally well tolerated by patients.3
■ Septal mucoperichondrial flaps inherently have little support, and if structural
support is lacking, late scarring and contracture can cause late nasal distortion,
stenosis, and obstruction.
■ Overall, flap infection or necrosis is rare given the abundant vascularity of the
face.1,5,7
■ Limited areas of flap necrosis can be managed conservatively and allowed to

heal secondarily if cartilage is unexposed.
■ Cartilage exposure may necessitate debridement to avoid infection and local
tissue necrosis.
REFERENCES
1. Westerveld GJ, Middelweerd RJ, Leemans CR. The hinged-door composite
septal flap as structural support and lining of nasal reconstruction by a
forehead flap. Rhinology. 2001;39(1):5-8.
2. Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty and
blood supply. Plast Reconstr Surg. 1989;84(2):189-202.
3. Collins JB, Czerwinski M. Contralateral dorsally based septal
mucoperichondrial page flap, for nasal lining reconstruction. J Craniofac Surg.
2015;26(4):1352-1354.
4. Menick FJ, Salibian A. Primary intranasal lining injury cause, deformities,
and treatment plan. Plast Reconstr Surg. 2014;134(5):1045-1056.
5. Aneeshkumar MK, Chueng K, Hart R, et al. Pivoted composite nasal septal
flap for reconstruction of the nose. Eur Arch Otorhinolaryngol.
2013;270(9):2445-2450.
6. Quetz J. Update on the septal pivot flap. Facial Plast Surg. 2014;30(3):300-
305.
7. Mureau MA, Moolenburgh SE, Levendag PC, Hofer SO. Aesthetic and
functional outcome following nasal reconstruction. Plast Reconstr Surg.
2007;120(5):1217-1227.
8. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast
Reconstr Surg. 1985;76(2):239-247.
9. Nour YA, Foad H. Swinging door flap technique for endoscopic transeptal
repair of bilateral choanal atresia. Eur Arch Otorhinolaryngol.
2008;265(11):1341-1347.

36
CHAPTER
Radial Forearm Flap for
Nasal Lining Reconstruction
Robert L. Walton and Brent Robinson
DEFINITION
■ Since its initial description by Yang et al. in 1978,1 the radial forearm flap has
been considered to be one of the most versatile flaps for nasal defect
reconstruction.
■ It provides for thin, well-vascularized tissue that is easily harvested, with
acceptable donor-site morbidity.
■ Unique to the radial forearm free flap (RFFF) is its ability to be partitioned
into separate islands for restoration of specific nasal lining elements such as
the nasal vestibule, floor, and columella.2
■ The free radial forearm flap is properly defined as a fasciocutaneous flap that
is primarily based on the radial artery and its venae comitantes (VCs).
■ One or two of the cutaneous nerve branches of the forearm (ulnar, median, or
lateral cutaneous nerves of the forearm) provide for sensibility of the flap if a
neurosensory configuration is required.3
■ The size of the flap can encompass any section of the skin and fascia from
the crease of the volar wrist to the antecubital fossa including the
circumferential forearm.
ANATOMY
Vascular Anatomy
■ The vascular anatomy of the radial forearm flap has been well elucidated.4 As
noted above, circulatory flow is provided by the radial artery and its associated
VCs (FIG 1A). The basilic and cephalic veins of the forearm are usually
included in large configurations of the flap, although the VCs provide for its

primary venous drainage.4 Its long vascular pedicle (8–12 cm) and generally
consistent anatomy make the radial forearm flap particularly advantageous for
nasal reconstruction.
Radial Artery
■ The radial artery originates just distal to the bicipital aponeurosis where the
brachial artery divides into the radial and ulnar arteries. In the proximal
forearm, the radial artery lies beneath the brachioradialis muscle and becomes
more superficial as it approaches the hand. The radial artery travels between
the heads of the first dorsal interosseous muscle to create the deep palmar arch
providing blood to the thumb and thenar side of the index finger. As the radial
artery becomes more superficial in the distal forearm, it gives off small
fasciocutaneous perforators that course superficially to supply the overlying
fascia and skin. These fasciocutaneous perforators constitute the primary
perfusion of the radial forearm skin.4 Saint Cyr et al. found an average of 24.6
radial artery perforators in the forearm, with the majority located distally and
over 50% of these having a radial orientation.4 The presence of these two main
clusters found along the distal and proximal thirds of the radial artery can
significantly facilitate flap planning and harvest.4
■ Although variations in radial artery anatomy are rare, its collateral
communications with the ulnar circulation in the hand should be confirmed
preoperatively by an Allen test at the wrist. In the most common configuration
of the deep palmar arch (Type A), it is formed by the anastomosis between the
deep volar branch of the radial artery and the deep inferior branch of the ulnar
artery.5 The superficial palmar arch (type A) is formed by anastomosis between
the superficial volar branch of the radial artery and the continuation of the
ulnar artery.5
■ The RFFF has two systems of venous drainage: a deep system composed of
two VCs accompanying the radial artery and a superficial system composed of
the cephalic vein and a series of subcutaneous veins (17). The profunda
cubitalis vein serves as the primary connection point between the two systems
(FIG 1B).6 The superficial system is based off the cephalic vein and a series of
meandering, subcutaneous venules that drain into it.7 The superficial venous
drainage is generally considered to have a consistent course and a favorable
caliber for subsequent anastomosis ranging from 3 to 6 mm.6 The cephalic vein
courses around the radial border of the forearm ascending along the ventral
aspect of the forearm toward the antecubital fossa, where it joins the basilic

vein. The cephalic vein drains the radial portion of the dorsum of the hand.
Deep venous drainage occurs with the paired deep VCs that travel along each
side of the radial artery with communicating tributaries. The VCs send off
paired branches at each ramification of the radial artery, reproducing a
triplicate pattern of vessels.7
■ Although widely studied, the controversy of one vs two venous anastomoses
still exists.8 Even though the published success rates of RFFF approach 95%, a
series of complicating factors still can lead to unpredictable venous
compromise postoperatively.8 In a retrospective cohort study of 370 radial
forearm free flaps, Selber et al. conducted a comparative analysis of the deep
vs the superficial drainage systems. They found that problems of inadequate
outflow are more commonly encountered when the cephalic vein is used to
drain the flap. When of adequate caliber (greater than 1 mm), they advocate
using the VCs as the sole venous outflow for the flap.7
■ As noted by Gottlieb et al., the VCs coalesce into a single vein at the level of
the brachial artery bifurcation. The profundus cubitalis vein (vena
anastomotica) connects the coalesced VCs to the cephalic vein at the level of
the cubital fossa.9 By dissecting the cephalic vein proximal to this point of
coalescence, both the deep and superficial venous systems can be drained via
one large anastomosis. Advantages of this technique include improved venous
drainage of very large radial forearm flaps, rendering the venous anastomosis
technically easier, due to its larger size, and more available versatility in
designing the venous portion of the vascular pedicle where the deep and
superficial systems join in the proximal forearm allowing for single outflow
vessel anastomosis.9 As noted, this configuration is reserved for large flaps that
wrap the radial forearm distally and extend the greater length of the forearm to
the wrist.

FIG 1 • Arterial (A), venous (B), and nerve (C), anatomy
of the radial forearm flap.
Nerve Supply

■ The medial and lateral antebrachial cutaneous nerves of the forearm provide
for cutaneous sensibility of the radial and volar forearm (FIG 1C). The lateral
antebrachial cutaneous nerve is a continuation of the musculocutaneous nerve
originating from C5 to C7 nerve roots and the lateral cord of the brachial
plexus, and it innervates the greatest surface area of the flap’s three overlapping
nerve territories.9 The nerve arises between the biceps brachii and the
brachialis muscles. It pierces the fascia radial to the biceps tendon in the cubital
fossa, passes posterior to the cephalic vein, and divides into anterior and
posterior branches. The larger anterior branch accompanies the cephalic vein
into the forearm and supplies the skin of the radial half of the anterior surface
as far as the thenar eminence. The smaller posterior branch supplies the skin of
the radial border and posterior aspect of the forearm as far as the wrist. The
medial antebrachial cutaneous nerve arises from C8 to T1 nerve roots. At the
junction of the middle and distal thirds of the forearm, the nerve emerges from
the brachial fascia running with the basilic vein and dividing into an anterior
and ulnar branch. The anterior branch supplies the anterior medial surface of
the forearm to the wrist; the ulnar branch passes anterior to the medial
epicondyle and supplies the skin on the forearm on its posteromedial surface.
■ An important attribute of the RFFF is its ability to provide restoration of
sensibility in reconstruction as a neurosensory fasciocutaneous flap. Studies
determining the long-term recovery of sensibility in flaps have shown
increased sensibility and better functional results with reinnervated flaps
compared to noninnervated flaps.10 The lateral antebrachial cutaneous nerve is
the dominant nerve of the radial forearm flap, providing sensibility to over
62% of the potential flap area. It is most commonly employed for restoring
sensibility in neurosensory configurations of the flap.10
■ Of special note is the superficial branch of the radial nerve (SBRN), the
branches of which are commonly encountered during elevation of the radial
edge of the flap (FIG 1C). These branches are highly vulnerable to injury
during flap elevation necessitating diligent care during this portion of the
dissection. The SBRN courses under the brachioradialis and between the heads
of the extensor carpi radialis longus just proximal to the radial styloid
process.11 When raising the flap, it is important to note the close relationship
between the cephalic vein and SBRN. If harvest of the cephalic vein is
undertaken by the surgeon during formation of the flap, an awareness of the
precise anatomical location of the SBRN in relationship to both the radial
artery and cephalic vein is essential to avoid neurologic injury.11 Flap donor-

site morbidity arising from injury to the SBRN has been documented by
Grinsell and Thiele (2005) to be between 9% and 18% depending on whether
the VCs or cephalic vein were included in the elevation, as raising the cephalic
vein doubled the risk of SBRN injury.12
PATIENT HISTORY AND PHYSICAL FINDINGS
■ If an Allen test is positive but concern still exists on the patency of the radial
artery, it is reasonable to obtain upper extremity arteriography for further
evaluation.
■ In a cadaver dissection of 650 cadaver arms, only 3.2% had no
communication between the radial and ulnar artery, and 3% had an
incomplete deep arch.13
■ If both of these variations are present, the thumb will be dependent on the
radial artery (approximately 1 in 1100).13 Vein graft reconstruction would be
necessary in these cases.
■ Other important components in the patient’s history include hand dominance.
It is preferable to harvest the flap from the nondominant upper extremity.
■ Additionally, hair growth patterns on the forearm are important aesthetic
considerations that may affect subsequent flap design and shape.
■ A critical issue in the use of the radial forearm free flap is prior cannulation of
the radial artery.
■ Arterial line catheterization traumatizes the intima, damaging vascular
outflow to the perforating branches by subjecting the radial forearm flap to
compromised perfusion and possible partial or complete loss.
■ Despite palpable radial pulses and a positive Allen test, flap perfusion may
still be compromised.
■ History of prior arterial line catheterization should prompt consideration for
use of a radial forearm flap from the opposite upper extremity or an alternate
flap.
IMAGING
■ Although the fine vascular perforators from the radial pedicle to the overlying
skin islands can be identified using magnified contrast angiography
preoperatively, we have not found such studies to be necessary owing to the
plethora of fine perforating vessels emanating from the radial system in the
distal forearm.
■ The distribution of these vessels in the distal forearm has proved to be fairly

consistent in our experience with adequate physiologic flow provided in over
100 consecutive multi-island flaps without any perfusion issues.
SURGICAL MANAGEMENT
Preoperative Planning
■ The first stage in reconstruction of total and subtotal nasal defects is
restoration of the nasal lining and adjacent cheek and upper lip elements
constituting the nasal base.14
■ This is usually accomplished with the microsurgical transfer of a radial
forearm flap to avoid compromising the local tissues and structures of the
midface and airway.
■ The nasal lining is composed of the floor, the nasal vestibules, and the
membranous septal element (in which the columella is repaired or the midline
septum is reconstituted).
T E C H N I Q U E S
■ Templating and Flap Design
■ The nasal site is dissected first, with excision of the remnant scar and any
skin grafts to recreate the original defect (TECH FIG 1A,B).
■ Templates of each of the missing lining and adjacent lip and cheek defects
are made of foil from surgical suture packets.
■ Care is taken to provide sufficient skin island separation so as to
accommodate the three-dimensional, anatomic positioning of these
elements at the nasal site.
■ We have found it useful to attach each of the foil templates with strips of
paper tape beforehand to replicate the radial vascular pedicle and then
determine the best three-dimensional configuration of the islands that
allows for their anatomic positioning without kinking the vascular pedicle
(TECH FIG 1C).
■ The flaps are then transferred to the forearm, where they are aligned to the
radial vascular pedicle as separate skin islands (TECH FIG 1D).
■ For the vestibular lining element, we have found it helpful to orient the
vascular pedicle at its cephalic edge so as to allow access to the nasal tip

and vestibule for placement of the supporting cartilage grafts and for
sculpting without injuring the vascular pedicle.
■ The vascular pedicle proximal to the skin islands should be at least 8 to 10
cm in length to allow it to span the distance from the nasal defect site to the
facial artery and vein at the inferior border of the mandible.
■ This precise distance is measured intraoperatively so that adequate pedicle
length is obtained during flap harvest. Although vascular repairs can
technically be performed more proximal near the nasal site, the marked size
variability and unpredictability of the venous anatomy at this level
necessitates accessing the facial system at a more anatomically predictable
site, ie, below the mandibular margin.
TECH FIG 1 • A. An 11-year-old girl had subtotal nasal
loss following a dog bite. B. Surgical preparation of
the nasal site involves excision of all scar tissue to
approximate the dimensions of the original wound.
C,D. Foil templates of the missing nasal elements are
joined with tape and aligned to the radial pedicle on
the volar forearm. (Reprinted from Walton RL, Burget
GC Beahm EK. Microsurgical reconstruction of the
nasal platform and lining. In: Nelligan PC, Wei FC,

eds. Microsurgical Reconstruction of the Head &
Neck. New York: Thieme Publishers, 2010:547-589
with permission.)
■ Flap Harvest
Confirmatory Dissection of The Radial Forearm Flap(s)
■ Preoperatively, an Allen test is performed to assure adequate hand perfusion
via the ulnar vascular pedicle.
■ The 1 to 3 island radial forearm flaps are dissected under tourniquet control.
■ The skin islands are kept attached at this stage of the dissection to facilitate
elevation.
■ The conjoined skin flap is dissected from its ulnar margin in a plane
superficial to the level of the forearm fascia (TECH FIG 2A).
■ The dissection terminates at the tendon of the flexor carpi radialis. Here, the
dissection transitions to the subfascial plane.
■ Small filamentous vascular branches emanating from the radial pedicle to
the undersurface of the flap are easily identified and protected (TECH FIG
2B).
■ On the radial side of the flap, the dissection proceeds through the
subcutaneous tissue to the volar surface and the ulnar border of the
brachioradialis tendon (TECH FIG 2C).
■ Care is taken here to identify and protect the dorsal sensory branches of the
radial nerve and the musculocutaneous nerve.
■ Occasionally, one or two small proximal branches of the radial sensory nerve
may be found entering the radial forearm flap.
■ These are divided, and the proximal stumps are buried in the adjacent
brachioradialis muscle to avoid painful neuroma formation.
■ The dissection then proceeds deep to the radial vascular pedicle, where
several relatively large branches emanating dorsally from the vascular
pedicle will be encountered.
■ These are ligated with 6-0 PDS absorbable sutures and divided.
■ At this point of the dissection, we have found it helpful to release the
tourniquet and evaluate flap perfusion.
■ In the rare circumstance in which perfusion of the skin island is sluggish or

compromised, further flap elevation should be abandoned or delayed. The
radial artery and venae comitantes (VCs) at this stage have not been
divided, so little is lost.
Completion Dissection and Elevation of the Radial Forearm
Flap(s)
■ If the skin island demonstrates satisfactory perfusion, the tourniquet is
reapplied and the flap elevation proceeds to completion.
TECH FIG 2 • A. The dissection commences on the
ulnar border of the flap with elevation superficial to the
deep fascia. At the radial edge of the flexor carpi
radialis (FCR), the dissection is directed deep to
include the radial artery and venae comitantes. B.
Fine filamentous perforators emanating from the radial
pedicle (arrows) to the overlying skin are preserved.
C. On the radial side of the flap, the subcutaneous
tissues are bluntly dissected to identify and preserve
the dorsal sensory branches of the radial nerve
(DSRN) and the distal sensory branches of the
musculocutaneous nerve (MCN). At the ulnar margin
of the brachioradialis tendon (BR), the dissection is
directed deep to include the radial artery and its VCs
(P). (Reprinted from Walton RL, Burget GC, Beahm
EK. Microsurgical reconstruction of the nasal platform
and lining. In: Nelligan PC, Wei FC, eds. Microsurgical
Reconstruction of the Head & Neck. New York:Thieme
Publishers, 2010:547-589, with permission.)

■ Distal to the skin island, the radial artery and its two VCs are dissected out
and ligated with fine 5-0 PDS absorbable suture and divided (TECH FIG
3A).
■ A forearm incision is made over the course of the proximal radial vascular
pedicle, and the vascular pedicle is dissected to its appropriate length with
ligation and division of its multiple forearm muscular branches (TECH FIG
3B).
■ In certain situations, the microsurgical venous anastomoses can be
simplified by dissection to the confluence of the VCs into a single vein just
proximal to the profunda cubitalis branch joining the cephalic vein.
■ After the flap has been isolated to the radial pedicle and the pedicle dissected
to length, the tourniquet is released and the flap is allowed to reperfuse.
■ The pedicle and skin islands are examined under magnification to assess
perfusion and to obtain final hemostasis (microbipolar and fine suture
ligature of small branches).
■ Separation of the skin islands and flap debulking are then performed.
■ The islands are dissected using loupe magnification, with care taken to
preserve the fine, filamentous vascular branches emanating from the
pedicle to each skin island.
■ Operative magnification is used to debulk selected areas of the flap
(especially the vestibular element) (TECH FIG 3C). This is accomplished
by incising the fibrous interstitium between the fat lobules and gently
teasing and suctioning the fat away by a process dubbed “liposuction.” We
have found this to be a very effective technique for performing the initial
debulking of the acute flap without compromising its blood supply.
TECH FIG 3 • A. The radial artery and venae
comitantes are ligated with fine sutures and divided
after adequate flap perfusion has been verified. B.

The flap pedicle is dissected proximally with ligation
and division of the multiple muscular branches. C. The
flap can be debulked using operative magnification
and selective excision of the fat globules peripheral to
the pedicle.
■ Dissection and Exposure of the Facial Artery and
Vein
■ The facial vessels are exposed through a 2-cm incision made just below and
parallel to the inferior mandibular border at the palpated notch or Doppler
site of the facial artery pulse (TECH FIG 4A,B).
■ The platysmal fibers are dissected apart longitudinally to expose the facial
artery and vein.
■ The marginal branch of the facial nerve is identified and protected.
■ A sub-SMAS tunnel connecting the nasal defect site with the facial vessel
site is created using blunt dissection with progressive Hegar cervical dilators.
■ The dilated tunnel is maintained with a 32 F chest catheter passed
subcutaneously from the facial incision site riding the end of the retracting
dilator for subsequent delivery of the vascular pedicle (TECH FIG 4C).
TECH FIG 4 • A. The facial vessels are accessed in
the upper neck 1 to 2 cm below the lower border of
the mandible. B. Dissection proceeds deep to the
platysma with care taken to identify and preserve the
marginal branch of the facial nerve. At this level, a
large facial vein (3 to 4 mm external diameter; X) and
facial artery (2 to 3 mm external diameter) (arrow) can

be identified. Occasionally, a large lymph node will be
encountered that obscures access to the facial vein—
dissection and removal of this lymph node will
facilitate access to the facial vein. C. After the facial
vessels have been dissected, a sub-SMAS tunnel is
bluntly dissected for passage of the flap pedicle. This
is progressively enlarged using cervical dilators. The
dilated tunnel is maintained with a 32 F chest catheter
that is passed in retrograde fashion behind the dilator.
(Reprinted from Walton RL, Burget GC, Beahm EK.
Microsurgical reconstruction of the nasal platform and
lining. In: Nelligan PC, Wei FC, eds. Microsurgical
Reconstruction of the Head & Neck. New York:
Thieme Publishers, 2010:547-589, with permission.)
■ Transfer of Flap to Facial Site
■ After the flap pedicle is divided, the flap is transferred to the nasal site where
the vascular pedicle is gently directed through the subcutaneous tunnel in the
cheek using the previously placed 32 F chest tube as a guide (TECH FIG 5).
■ Gentle suction and a continuous drip of lactated Ringer solution for
lubrication allow passage of the pedicle with avoidance of any vascular
branch ligature avulsion or inadvertent twisting.
■ Following delivery of the vascular pedicle through the cheek to the facial
vessel site, the chest tube is then withdrawn, allowing the soft tissues to
collapse around the unsullied pedicle.
■ The flap is temporarily secured to the nasal site with 4-0 silk sutures.

TECH FIG 5 • A. Detached flap reader for transfer. B.
At the facial site, the flap pedicle is delivered through
the cheek via the previously placed chest tube. Using
saline drip irrigation as lubricant and gentle suction,
the pedicle is delivered to the anastomotic site. This
technique allows for accurate placement of the pedicle
with minimal risk for twisting or shearing of side
branch ligatures. (Reprinted from Walton RL, Burget
GC, Beahm EK. Microsurgical reconstruction of the
nasal platform and lining. In: Nelligan PC, Wei FC,
eds. Microsurgical Reconstruction of the Head &
Neck. New York: Thieme Publishers, 2010:547-589,
with permission.)
■ Flap Inset
■ The vascular repairs are performed end to end to the facial artery and vein.
Although no systemic anticoagulation is used, we routinely employ high-
concentration heparin irrigation (50 000 units heparin/100-cc lactated Ringer
solution) while performing the vascular anastomoses.
■ Aspirin (81 mg) is also administered intraoperatively and for 21 days
postoperatively for its prostacyclin and antiplatelet effects.
■ Following re-establishment of vascular inflow, the flap islands are arranged
anatomically at the nasal site and inset with fine sutures (TECH FIG 6A).
■ To avoid contraction of the nasal vestibular lining elements, we have found it
useful to brace the vestibular element with small grafts of cadaver allograft

cartilage placed in the midline and along the caudal edge of the vestibule and
secured with 6-0 PDS suture (TECH FIG 6B,C).
■ The undersurface of the vestibular element, which now lies externally, is
closed with a full-thickness skin graft from the inguinal region (TECH FIG
6D,E).
■ When placed over the supporting cartilage allografts, the take of the full-
thickness skin graft is not compromised, as a result of its excellent capacity
for bridging.
■ When the grafted area is large, a fine suction drain, fashioned from a 22-
gauge butterfly intravenous needle, is placed beneath the skin graft to
facilitate graft adherence and promote serous drainage.
■ A simple petroleum jelly–impregnated gauze/mupirocin dressing is applied
to the grafted vestibular element.
■ No internal nasal packing or stents are employed.
TECH FIG 6 • A. Following re-establishment of
vascular inflow, the flap islands are arranged
anatomically at the nasal site and inset with fine
absorbable (chromic) sutures. B. The vestibular
element is temporarily stented with cadaver cartilage
allografts to prevent shrinkage in the interim between

the microsurgical lining flap and the placement of
permanent skeletal support (autologous cartilage
grafts) and a forehead flap for external cover. The
graft (G) is seen spanning the vestibular element and
lying beneath the vascular pedicle (P). C. These
cartilage allografts (G) are placed along the
longitudinal axis of the vestibular element and at the
nostril margins and secured with 6-0 PDS sutures.
D,E. Following inset of the flap islands, the exposed
undersurfaces of the flaps are closed with full-
thickness skin grafts. Full-thickness grafts stifle
contraction and are useful for bridging the cadaver
cartilage allografts stents. During the second stage of
reconstruction, the skin grafts and cadaver cartilage
grafts are removed. (Reprinted from Walton RL,
Burget GC, Beahm EK. Microsurgical reconstruction
of the nasal platform and lining. In: Nelligan PC, Wei
FC, eds. Microsurgical Reconstruction of the Head &
Neck. New York: Thieme Publishers, 2010:547-589,
with permission.)
■ Closure of the Forearm Donor Site
■ We routinely employ a full-thickness skin graft harvested from the inguinal
region, which provides very stable coverage for the distal volar forearm
donor site.
■ It is pliable, exhibits minimal contraction, and is aesthetically quite
acceptable (TECH FIG 7).
■ A template of the forearm defect is transferred to the inguinal region where it
is incorporated within the confines of an ellipse, the longitudinal axis of
which is aligned with the inguinal fold.
■ For large defects, the graft may need to be applied as articulated segments
derived from the confines of the ellipse.
■ The graft is inset using 4-0 silk sutures that are used to secure a sponge stent.

Following application of the stent dressing, the forearm and hand are
wrapped in a light compression bandage composed of Kerlix fluffs, Reston
foam, Kling wrap, and an Ace wrap secured with staples.
TECH FIG 7 • Full-thickness skin grafts are preferred
for closure of the forearm donor site. Here a grafted
forearm donor site is shown one year postoperatively.
PEARLS AND PITFALLS
Timing
■ For complex flap shapes, we have found that delay of the radial
forearm flap is advantageous for augmenting dermal perfusion, and
we do this routinely 10–14 days prior to flap transfer. The flap is
incised all around and elevated to a variable degree above the forearm
fascia depending on the size and shape complexity of the flap island.
For nasal lining–only defects, two delays are performed 3–4 weeks
apart.
Tendon
protection
■ Prior to making the skin incision, the brachioradialis and flexor carpi
radialis tendons are identified at the volar wrist and traced proximally.
These structures will form the boundaries of the “no-fly zone,”
defining the traverse of the radial pedicle and its perforators to the
overlying skin paddle. In most cases, we prefer to harvest the flap in
the suprafascial plane, preserving the deep fascia for coverage of the
flexor tendons and nerves. This results in less donor-site morbidity
and allows for selective thinning of the flap as necessary for nasal
lining reconstruction.
Perforators
■ When harvesting multiple islands, it is important to use magnification

(loupe or operating microscope) to identify the radial perforators to
each island. After the islands have been dissected, care should be
exercised to protect each island from shear or twisting forces that
might injure the perforating vessels.
Flap
thickness
■ Do not underestimate the thickness of this flap despite its apparent
thinness in situ. This is especially relevant when transferring the flap
to the face for use in nasal lining reconstruction or external nasal
cover. Direct debulking of the flap prior to transfer can be effectively
accomplished by using operative magnification to visualize the fat
globules allowing for their lysis and direct suction removal with care
to avoid injury to the radial pedicle perforators and the subdermal
vascular plexus. In obese patients, pretransfer debulking/delay of the
flap is essential for avoiding the typical “meatball” appearance that
results from transfer of the full subcutaneous thickness of the flap.
■ In certain reconstructions in which the flap is tubed for reconstruction
of the columella, it is important not to coapt the opposing edges under
tension as this may compromise of the blood flow. In these cases, it is
helpful to apply a small full-thickness skin graft between the folded
edges of the flap to ease the tension. These grafts do quite well,
provided adequate hemostasis is achieved prior to application of the
skin graft. If necessary, they can be excised at the time of flap
debulking and contouring usually 6–8 weeks following transfer.
POSTOPERATIVE CARE
■ The flap reaches maximal swelling at 48 hours.
■ Close observation must be maintained to assure that this swelling does not
interfere with flap perfusion especially if multiple islands are used.
■ If there is any concern about flap perfusion as the swelling ensues, release of
several inset sutures may be all that is necessary to relieve the tension and
improve flap perfusion.
■ Once the swelling subsides, and usually within 3 to 4 days, the sutures can be
replaced.
■ If the flap is transferred to the face, care must be taken to avoid the use of cool
mist face masks or blow-by oxygenation as these may result in excessive
cooling of the flap, which induces vasospasm and subsequent thrombosis.
■ To avoid this complication, insist on the use of warm (steam) humidification
for all oxygenation adjuncts and be sure to personally check this to assure that
no cool mist is contacting the flap.
■ The forearm donor-site bandage is kept in place for 1 week. It is preferable to

not use arm slings as these tend to produce shoulder stiffness, especially in
older patients; patients are instructed to carry their bandaged arm upright, with
overhead elbow stretching on postoperative day 1.
■ The stent dressing is removed and graft take is assessed at 1 week. The graft is
redressed with a petrolatum dressing and a light gauze wrap and ace bandage.
■ At 10 days postoperatively, the sutures are removed and moisturizing creams
are applied.
■ The forearm is kept wrapped with an ace bandage or Coban elastic bandage
applied by the patient for 6 weeks to stifle hypertrophic scarring and promote
contouring of the forearm donor site.
OUTCOMES
■ Use of the radial forearm flap for restoration of the nasal lining elements has
proved to be a very reliable approach for management of challenging total and
subtotal nasal defects.
■ In more than 150 such cases, we have experienced only one total flap failure
and six partial losses. The total flap failure occurred in a patient with Wegener
granulomatosis with protein C deficiency who exhibited flap necrosis on the
4th postoperative day despite normal Doppler signals. Three partial flap losses
were associated with prior radial artery cannulation.
COMPLICATIONS
■ Complications inherent to the radial forearm flap are few as this is a very
robust flap with large-caliber vessels and an infinite assortment of
configurations and applications.
■ As noted above, be wary of using the radial forearm flap if prior
catheterization of the radial artery has been performed, even if the Allen test
demonstrates patent communication between the radial and ulnar systems.
When using the flap around hardware, be cognizant of the fact that hardware
can very quickly occlude the pedicle especially as the flap swells.
■ In these cases, judicious placement of the pedicle away from any restricting
hardware or bone graft will be good insurance against middle of the night
phone calls. If the pedicle is oriented toward the edge of the flap, as in nasal
reconstruction, it is often helpful to delay the flap to assure adequate perfusion
of the skin island.
■ Previous trauma to the forearm with visible scarring on its volar surface should
raise caution about the potential for vascular perfusion problems. In these

cases, surgical delay or choice of a different flap (or arm) is warranted.
■ Over the years, we have encountered several instances of vascular spasm
induced by flap contact with cool moist humidified air provided by face mask
or head tent devices by respiratory therapy.
■ The small size of these nasal lining flaps makes them especially vulnerable to
ambient air temperatures.
■ If postoperative patients require supplemental oxygen, it is important to
deliver this as a warm moist humidified flow to avoid temperature-induced
vasospasm.
■ Experience has shown that flaps incorporating previous forearm tattoos are at
risk for vascular compromise and partial flap necrosis.
■ For these small flaps, it is recommended that tattoo areas of the volar forearm
be excluded from the flap design whenever possible.
■ After flap healing, the second stage of nasal reconstruction involves removal
of the skin graft cover, debulking of the vestibular lining element, placement of
cartilage support grafts, and application of a paramedian forehead flap for
external cover.
■ Care must be taken during this stage to avoid creating any holes in the
vestibular lining flap that might communicate with the nasal airway to avoid
infection.
■ If the radial forearm lining flap has been compromised during the dissection,
these injuries should be meticulously repaired. We have found it useful to
cover these repair sites with small dermis grafts as an added level of
protection.
REFERENCES
1. Yang GF, Chen B, Gao Y. Forearm free skin flap transplantation. Natl Med J
China. 1981;61:139-142.
2. Burget GC, Walton RL. Optimal use of microvascular free flaps, cartilage
grafts, and a paramedian forehead flap for aesthetic reconstruction of the nose
and adjacent facial units. Plast Reconstr Surg 2007;120:1171.
3. Mulhbauer W, Herndl E, Stock W. The forearm flap. Plast Reconstr Surg.
1982;70:336.
4. Saint-Cyr M, Mujadzic M, Wong C, et al. The radial artery pedicle perforator
flap: vascular analysis and clinical implications. Plast Reconstr Surg.
2010;125:1469-1478.
5. Gellman H, Botte MJ, Shankwiler J, Gelberman RH. Arterial patterns of the

deep and superficial palmar arches. Clin Orthop Relat Res. 2001;(383):41-46.
6. Liu Y, Jiang X, Huang J, et al. Reliability of the superficial venous drainage of
the radial forearm free flaps in oral and maxillofacial reconstruction.
Microsurgery. 2008;28:243-247.
7. Selber JC, Sanders E, Lin H, Yu P. Venous drainage of the radial forearm free
flap comparison of the deep and superficial systems. Ann Plast Surg.
2011;66(4):347-350.
8. Bai S, Xu ZF, Duan WY, et al. Single superficial versus dual systems venous
anastomoses in radial forearm free flap: a meta analysis. PLoS One.
2015;10(8):e0134805.
9. Gottlieb LJ, Tachmes L, Pielet RW. Improved venous drainage of the radial
artery forearm free flap: use of the profundus cubitalis vein. J Reconstr
Microsurg. 1993;9(4):281-284.
10. Boutros S, Yuksel E, Weinfeld AB, et al. Neural anatomy of the radial
forearm flap. Ann Plast Surg. 2000;44(4):375-380.
11. Robson AJ, See MS, Ellis H. Applied anatomy of the superficial branch of
the radial nerve. Clin Anat. 2008;21(1):38-45.
12. Grinsell D, Theile D. Radial nerve morbidity in radial artery free flaps:
harvest of cephalic vein versus venae comitantes. ANZ J Surg. 2005;75(7):542-
545.
13. Coleman SS, Anson BJ. Arterial patterns in the hand based upon a study of
650 specimens. Suvr Med (Sofiia). 1961;113:409.
14. Walton RL, Burget GC, Beahm EK. Microsurgical reconstruction of the nasal
lining. Plast Reconstr Surg. 2005;115:1812-1829.

37
CHAPTER
Nasal Reconstruction With
Skin Grafts and Composite
Grafts
Steven M. Levine and Daniel C. Baker
DEFINITION
■ Nasal defects are frequently not amenable to primary closure without
distortion of the underlying cartilaginous structure or obvious repositioning of
the nasal tip or ala.1
■ Nasal defects are commonly treated with the local flaps or local regional flaps.
■ The ideal reconstruction is skin of similar color, thickness, and texture.
■ One-stage reconstruction is an attractive option to both patient and surgeon.
■ Full-thickness skin grafts, for the purposes of this text, include the epidermis,
dermis, and often adipose tissue.
■ Composite grafts include both a component of skin as well as cartilage.
ANATOMY
■ Nasal anatomy is often divided into aesthetic subunits.
■ These subunits are a useful guide but quite frequently can be ignored when
reconstructing the nose with full-thickness skin grafts or composite grafts.
■ Maximizing surface area for graft take is of primary concern when using full-
thickness skin grafts or composite grafts.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Skin/subcutaneous defects on the nose may be treated in many cases with a
full-thickness skin graft. However, if the defect includes missing cartilage or
would benefit from extra-anatomical cartilage (such as an alar rim or tip), a
composite graft should be considered.
■ The defect must have an appropriate graft recipient bed to accept either graft.

■ This means if the wound has been heavily cauterized during the resection
portion of the procedure, excisional debridement and local wound care should
be performed until a suitable bed is present.
■ If the defect is contaminated as in the case of a dog bite or motor vehicle
accident, debridement and local wound care should be performed until a
clean recipient bed is present.
■ Care should be taken to note the length, width, and depth of the defect.
SURGICAL MANAGEMENT
■ Full-thickness skin grafting or composite grafting can be performed under
local anesthesia, sedation, or general anesthesia, depending on the preference
of the surgeon and the patient.
Preoperative Planning
■ The primary consideration for preoperative planning is to define the extent of
the defect and identify a suitable donor site.
■ In general, color match is improved by selecting a donor site that is
anatomically close to the nose (eg, the ear, preauricular skin).
■ These grafts have better color and texture match to the nose.
■ The preauricular region is an ideal donor site and usually heals with an
inconspicuous scar. Strong preference is given to this site vs the retroauricular
site despite the natural inclination to use the more “hidden” skin behind the ear.
■ Occasionally, the supraclavicular skin is good color and texture match for the
nose.
■ The surgeon should identify the components of the donor tissue required to
optimize the aesthetic outcome.
■ Frequently, a thin layer of adipose tissue should be harvested with the grafts
to allow for appropriate depth matching between the graft and the recipient
site.
■ It is important to avoid overthinning of full-thickness skin grafts as this may
result in late contracture or a cobblestone appearance of the graft that is
difficult to address.
■ The two most common donor sites for composite grafts used for nasal
reconstruction are the anterior helical rim, which can be harvested along with a
pennant of preauricular skin, and the conchal bowl, which can be harvested
with either conchal skin or retroauricular skin.

Positioning
■ The patient is either supine if under sedation or full anesthesia or sitting
reclined or supine in an exam chair if performing the graft on an awake patient.
Approach
■ The approach to the graft can be varied from surgeon to surgeon with a
consistent emphasis on delicate handling of the graft both at the time of harvest
and when securing it to the recipient site.
T E C H N I Q U E S
■ Graft Repair of Nasal Defect
Site Preparation and Graft Harvest
■ The donor site and recipient site are cleaned with alcohol and then prepped
with Betadine.
■ A small amount of eye ointment is placed on the sclera to protect the eyes if
using anesthesia.
■ First, the recipient site is defined. This means that any nonviable tissue is
debrided and a fresh wound edge is created using a sharp knife to bevel the
perimeter (TECH FIG 1).
■ Hemostasis should ideally be obtained using pressure and patience to avoid
burning the recipient site and impeding graft take.
■ Very light cautery can be used if needed.
■ After the recipient site is prepared, a foil template is made and transferred to
the donor site.
■ If a composite graft is planned for an alar defect with a lining deficiency that
is greater than 8 mm, it will usually require a turndown flap.
■ The authors prefer to use the adjacent sidewall skin as a turndown flap that is
secured using 5-0 absorbable suture.
■ Other surgeons prefer a septal hinge flap, but we find this flap to be flimsy
and difficult to control.

TECH FIG 1 • Recipient site prepared.
■ The graft is harvested entirely with a knife, and the edges are beveled.
■ If the graft is a composite graft with cartilage, care is taken to not separate
the cartilage from its attachments to the surrounding skin.
Graft Placement
■ If alar reconstruction is being performed, a tongue in groove closure is
performed with the composite graft cartilage and the recipient alar rim—in
other words, extend the graft cartilage beyond the skin and use this additional
cartilage to insert in both lateral recipient sites.
■ 6-0 monofilament sutures are used to sew the grafts to the deep recipient bed
to minimize potential space.
■ The graft is secured usually using 6-0 nylon suture in the recipient bed
(TECH FIG 2).
■ Prior to finishing, a 20-gauge angiocatheter is used to irrigate beneath the
flap with saline.
■ If a bolster is used, it is secured to the flap with tape, not suture.
■ The donor site is closed primarily, elevating tissue where needed to
minimize tension on the closure.

TECH FIG 2 • Composite graft sewn in place with
edges beveled and delicately approximated to
surrounding tissue. Conchal skin was harvested with
cartilage to add structure to avoid notching the alar
rim.
PEARLS AND PITFALLS
Handle grafts
with care
■ Do not cauterize when harvesting the grafts. Do not inject local
anesthesia through the graft, rather inject around the graft.
Graft take is
a reflection of
the health of
the recipient
bed
■ Exercise patience when determining the appropriate timing for the
graft. Fresh eschar is not a suitable recipient bed as in the case of a
cauterized post-Mohs defect. Use local wound care principles to
obtain a health granulation bed prior to grafting.
6-0
monofilament
sutures to
minimize
potential
■ These small monofilaments and accompanying small needles are
an excellent alternative to through-and-through basting sutures.

space
Meticulous
postgraft
care
■ See these grafts frequently over the first few days. Minor problems
can be treated thereby avoiding major problems. Small collections
can be rolled out from beneath the graft; Silvadene can be used in
compromised regions. Often, epidermolysis heals and completely
recovers.
FIG 1 • The patient in TECH FIGS 1 and 2 one year
after composite graft for alar rim reconstruction.
POSTOPERATIVE CARE
■ Tie-over bolsters have been abandoned in favor of either no bolster (for grafts
smaller than 1 cm) or a small Xeroform bolster covered with nonstick gauze
and tape.
■ Cool packs are also used to reduce swelling and have reportedly been shown
to improve graft survival by lowering the metabolic requirement of the grafted
tissue.
■ Patients are instructed to use cool compresses at home for the first 12 hours.
■ Patients are seen back in the office the following morning, and any dressing
over the graft is removed, and a cotton-tipped applicator is used to roll over the
graft and express any collected fluid to avoid interference with graft
imbibition. This is repeated daily for the first 2 or 3 days.
■ Silvadene 1% is used TID on any compromised area of the graft.
OUTCOMES
■ The surgeon should follow their first several grafts very closely to understand

the progression of healing so that they know what to expect and can covey to
the patients the normal healing of the grafts.
■ In the case of composite graft (or full-thickness grafts with significant adipose
tissue), they are usually pale for the first day, then turn blue (congestion) for 2
or 3 days, but a small amount of pink hue is usually seen behind the blue and
emerges dominant between days 5 and 6 (FIGS 1 to 4).
■ Healing goes on for at least 1 year after grafting, and all revisions should
ideally be considered only after this point.
FIG 2 • Full-thickness skin graft with preservation of fat
for nasal tip reconstruction. A. Preoperative. B. Eleven
months postoperatively.

FIG 3 • Full-thickness skin graft with preservation of fat
for nasal tip reconstruction. A. Preoperative. B. Eleven
months postoperatively.
COMPLICATIONS
■ The most feared complication is complete graft loss. This is exceedingly rare.
■ Partial graft loss can occur and is usually the result of an inadequate graft bed
or retained fluid collection beneath the graft.
■ Step-offs between graft skin and native skin can occur if appropriate beveling
of the recipient site and graft are not carried out.
■ Infections can occur but should be minimized with appropriate aseptic
technique. The authors do not use routine postoperative antibiotics.
■ Blood pressure control is important to prevent recipient site bleeding and graft
loss.
REFERENCE
1. Casson PR, Baker DC. Reconstruction of defects following Mohs’ surgery. J
Dermatol Surg Oncol. 1981;7(10):811-817.

FIG 4 • Composite graft for alar rim reconstruction.
Conchal skin was harvested with cartilage to add
structure to avoid notching the alar rim. A. Preoperative.
B. Five months postoperatively.

38
CHAPTER
V-Y Advancement Flaps for
Nasal Reconstruction
Julian J. Pribaz and Simon G. Talbot
DEFINITION
■ There are multiple different types of V-Y flaps. It is important to differentiate
these especially with respect to their use in nasal reconstruction, as they must
be applied correctly for successful outcome:
■ A classic V-Y flap refers to a triangle-shaped island flap designed at one edge
of a defect with the tapering V part distal to the defect (FIG 1A).
• It is based on a mobile subcutaneous pedicle.
• As the triangular flap is advanced into the defect, the residual donor site is
closed primarily, resulting in a Y-shaped scar.
• It is essential that there is an adequate and mobile pad of subcutaneous fatty
tissue to allow flap advancement.1,2
■ The extended V-Y flap is a modification of the V-Y advancement flap, with
the addition of an extension limb onto the advancing edge of the standard
flap (FIG 1B).
• The limb is located adjacent to the area requiring reconstruction and is
elevated from its bed and hinged down as a transposition flap on the end of
the V-Y advancement flap to close the most distal part of the defect.
• A double extended V-Y flap is an even larger flap, with an extension limb on
each side of the defect, so that both limbs are transposed onto the advancing
edge of the V-Y flap, which itself is based on a mobile subcutaneous
pedicle.3

FIG 1 • Perforator V-Y flaps based on the angular artery,
showing a regular V-Y design for a more vertically
oriented defect (A) and an extended V-Y design for a
more medial and circular defect (B).
■ The V-Y perforator flap is an entirely different concept, and the only
similarity with the above is that the eventual donor-site closure goes from a V
to a Y configuration.
• Unlike the regular V-Y flaps, the perforator flaps are not based on a broad
mobile subcutaneous pedicle but rather on specific perforating vessels that
must be mobilized for flap advancement.
ANATOMY
■ The cutaneous anatomy of the nose is not uniform.
■ The skin in the upper half is thinner and has a variable amount of underlying
subcutaneous fat, with the most mobility over the nasal bridge just below the

glabella.
■ The lower half of the nose is thicker and more sebaceous and also much
more adherent with very little mobility due to lack of subcutaneous fat.
■ The blood supply is rich and comes from the paired angular arteries and
accompanying veins.
■ The angular artery starts at the alar base as a continuation of the facial artery
and runs in the trough between the nasal side wall and adjacent cheek. It
anastomoses with the infraorbital, infratrochlear, and dorsal nasal vessels and
across the midline with corresponding vessels on the opposite side. It gives
multiple small perforators that pass both medially onto the nose and laterally
onto the cheek (FIG 2).4
■ There is relatively loose areolar tissue with some fat around the pedicle, which
provides flap mobility.
■ The type of V-Y flap that can be used successfully will depend on the location
of the defect on the nose.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients present with small, yet often challenging, defects of the nose that are
usually the result of tumor excision.
■ In many cases, these patients have undergone Mohs surgery involving
complete excision of the tumor with clear microscopic margins, making it
safe to proceed with immediate reconstruction.
■ The location, size, shape, and orientation of the defect are important in
determining the method of reconstruction.
■ The goal is to restore the nose to as near normal as possible, especially with
respect to the contour restoration with no distortion to the natural landmarks of
the nose.
■ Any surgery will produce scars, but contour restoration is more important
because scars do settle and mature with time to becoming less conspicuous.
■ Ideally, the use of adjacent local tissue will ensure that the best color and
texture will be restored.

FIG 2 • Vascular supply to the nose. The angular artery
starts at the alar base as a continuation of the facial
artery and runs in the trough between the nasal side
wall and adjacent cheek. It anastomoses with the
infraorbital, infratrochlear, and dorsal nasal vessels and
across the midline with corresponding vessels on the
opposite side.
■ The use of V-Y advancement flaps brings in local “like tissue” that causes a
minimum distortion.
■ The type of V-Y flap that is used depends on the site of the defect.
■ The classic V-Y flap is possible only in the proximal nose across the nasal
bridge, where there is more subcutaneous tissue and the flap can be advanced
effectively and expeditiously in a transverse direction.
■ For defects of the distal half of the nose, a perforator type V-Y flap is used.
This may be extended or doubly extended for additional reach (see FIG 1).
■ For vertically oriented defects, a perforator flap without extensions will

suffice.
■ For round, more transversally oriented defects or defects that are more
medially located, an extended type of V-Y perforator flap is needed.
SURGICAL MANAGEMENT
Preoperative Planning
■ For simple V-Y flaps across the nasal bridge, no special planning is needed
other than accessing the mobility of the soft tissues and designing the
transverse V-Y flap.
■ For defects in the distal half of the nose, the beginner should use a Doppler
ultrasound to map out the angular artery and perforators, but once experienced,
this is not necessary because there are consistent, multiple perforators.
■ The flap is designed adjacent and lateral to the defect, with the V component
extending across the nasal-cheek junction to capture the perforators.
■ The orientation of the flap has a slight downward or oblique tilt, so that
eventually once transferred into the defect, the flap is entirely on the nose and
does not cross the nose-cheek junction.
Positioning
■ The procedure is short and usually performed under local anesthesia in a day
surgery setting, with the patient in supine position.
■ The procedure could be done under MAC anesthesia or rarely under general
anesthesia.
■ It is best to inject the local anesthetic before prepping and draping the patient
to allow the anesthetic and epinephrine to take effect.
■ We have not had any problems with the use of epinephrine with the local
anesthetic.
Approach
■ The approaches are different according to the type of V-Y flap as described
above.
■ Loupe magnification may be used for the perforator-type flap dissection,
especially if inexperienced.
T E C H N I Q U E S

■ Classic V-Y Flap for Proximal Nasal Defects
■ The usual defect is on the lateral side of the nasal bridge and medial canthal
area.
■ A transversely oriented V-Y flap is designed and infiltrating with local
anesthesia.
■ Once this has taken effect, simple skin incision and minimal blunt dissection
is adequate to mobilize the flap and complete the repair (TECH FIG 1).
TECH FIG 1 • Basal cell carcinoma of the left inner
canthus marked to be excised and repaired with
classic V-Y flap.
■ Perforator V-Y Flap for Defects of the Distal Half
of the Nasal Side Wall and Supra-alar Region
Standard Perforator V-Y Flap
■ The flap is marked as described above (TECH FIG 2A).
■ Local anesthesia with epinephrine is infiltrated along the flap margins,
including the nose-cheek junction where the perforators are located.
■ The skin is incised, and the flap nearest the defect is completely elevated off
the underlying tissue toward the nose-cheek junction.
■ The lateral V aspect of the flap is incised down to the subcutaneous tissue

only, and then blunt, spreading type of dissection is performed with fine
scissors, teasing out the deeper subcutaneous fatty tissue and the perforators.
■ The perforators are readily visualized, but no attempt is made to isolate the
flap on a single perforator (TECH FIG 2B,C).
■ The mobilization is continued until adequate mobilization has been achieved
to allow the flap to move into the defect with minimum tension.
■ The inset is performed in a single layer, with nylon attempting to evert the
wound edges for a better repair and help to minimize pincushioning due to
scar contracture (TECH FIG 2D).
■ Deeper absorbable sutures are used to repair the donor site, with the repair
falling along the nasolabial fold.
■ The flap appears pink, well perfused, and not congested at the end of the
operation despite the use of epinephrine with the local anesthetic.
■ This is usually performed as a single-stage procedure, but secondary minor
scar revisions may occasionally be required.
Extended Perforator V-Y Flap
■ For more medially located defects, or more transversely oriented defects, an
extended type of flap design is used, and the advancing extension wings are
sutured together to increase the reach.
■ The suture line of the extension flap often falls along a natural crease line
at the junction between the alar subunit and the lateral domal subunit, so it
becomes less conspicuous with time (TECH FIG 3).
■ Perforator V-Y flaps are generally not indicated for defects involving the
nostril margins.
■ Although the V component of the flap starts on the cheek, after transfer, it
should lie completely within the nose, with Y closure being made along the
nasolabial fold.
■ The V-Y perforator flap should not disrupt the alar subunit. Its lower border
can be just along the supra-alar crease, but not cutting across it or distorting
it.

TECH FIG 2 • A. Patient following Mohs surgery with a
more circular defect medially located, with perforator
flap design. Perforators marked as dots along nose-
cheek junction. B. Perforator dissection medially. C.
Perforator dissection laterally. D. Flap inset.

TECH FIG 3 • A. Patient with defect at domal/alar
groove with flap marked curving over the alar subunit.
B. Flap inset.
PEARLS AND PITFALLS
Indications
and
assessment
■ Have a clear understanding of the different types of V-Y flaps that
may be used for nasal reconstruction and where they can be
applied.
Technique
■ Cannot do a conventional V-Y flap in the distal half of the nose
due to lack of mobile subcutaneous tissue.
■ Where there is limited tissue mobility, a perforator-type flap is
required. Do not skeletonize the pedicle.
■ An extended perforator V-Y flap is required for larger, transversely
oriented, and more medially located defects.
■ Perforator V-Y flaps can “start on the cheek” but must “end up on
the nose.” It should not span the nose-cheek junction.
■ Inset flap with everting suturing to minimize pincushioning.
POSTOPERATIVE CARE
■ Skin-colored Steri-Strips are usually applied as the only dressing.
■ The Steri-Strips may need to be replaced in a day or so if they become blood

stained.
■ The sutures are removed at a week and the usual scar management protocol
followed.
OUTCOMES
■ The V-Y flap provides a simple and reliable way of reconstructing small yet
difficult nasal defects, either of the bridge of the nose with a simple V-Y flap or
distal half of the nose with a perforator V-Y flap, both providing an aesthetic
reconstructive outcome (FIG 3).5,6
COMPLICATIONS
■ Scar contracture and pincushioning can be minimized with careful and
everting skin edge suturing.
■ Minor scar revisions can be performed if needed once the scars have had a
chance to maturate.

FIG 3 • Postoperative appearances of the patients in
TECH FIGS 1A, 2B, and 3C,D.
REFERENCES
1. Barron JN, Emmett AJ. Subcutaneous pedicle flaps. Br J Plast Surg.
1965;18:51.
2. Zook EG, Van Beek AL, Russell RC, Moore JB. V-Y advancement flaps for
facial defects. Plast Reconstr Surg. 1980;65:786.
3. Pribaz JJ, Chester CH, Barrall DT. The extended V-Y flap. Plast Reconstr
Surg. 1992;90:275-280.
4. Whetzel TP, Mathes SJ. Arterial anatomy of the face; an analysis of vascular

territories and perforating cutaneous vessels. Plast Reconstr Surg.
1992;89:591-603.
5. Guo L, Pribaz JR, Pribaz JJ. Nasal reconstruction with local flaps: a simple
algorithm for management of small defects. Plast Reconstr Surg.
2008;122:130e-139e.
6. Parrett BM, Pribaz JJ. An algorithm for treatment of nasal defects. Clin Plast
Surg. 2009;36:407-420.

39
CHAPTER
Section XI: Cavity and
Pharynx
Facial Artery Perforator Flap
Julian J. Pribaz and Simon G. Talbot
DEFINITION
■ Perforator flaps are a relatively recent addition to our reconstructive
techniques.
■ They have evolved as a result of meticulous studies of vascular blood supply
to the skin, which have demonstrated a rich network of perforator vessels
arising from all major vessels, allowing for the elevation of safe and
customized flaps based on these vessels.
■ The facial artery is the major vessel supplying the lower half of the face.
Multiple innovative flaps have been developed based on perforators arising
along the course of the facial artery, including flaps in the perioral region,
which is the subject of this chapter.1–6
ANATOMY
■ Arterial
■ The facial artery enters the face by hooking around the lower border of the
mandible at the anterior edge of the masseter muscle. It follows a tortuous
course through the cheek, passing upward and medially toward the oral
commissure and then to the alar base, where it becomes the angular artery
(FIG 1).
■ It passes deep to the muscles of facial expression and gives off two major
named vessels—the inferior and superior labial arteries—as well as multiple
perforators to all surrounding structures, including the superficial and deep
muscles, skin, and mucosa.

• Hofer mapped out the perforators supplying the skin and found that these
were multiple, with at least three perforators having an average diameter of
1.2 mm. His injection studies showed that a single perforator can supply a
large area of facial skin, thus making it useful for perioral reconstruction.7
FIG 1 • Arterial supply of the lower face and mouth.
■ Venous
■ The main facial vein does not run with the artery but is located more laterally
in the cheek and approaches the facial artery near the angle of the mandible.
■ There are multiple small venous channels in the soft tissues that provide
adequate drainage to perforator flaps. However, it is important not to
skeletonize the pedicle but rather leave a cuff of soft tissue to allow for
venous drainage.
■ This is an important distinguishing feature of facial artery perforator flaps
compared with those harvested from other parts of the body in which the
perforating vessels are routinely skeletonize to maximize flap reach and
rotation. Because of the tortuous nature of the artery and the mobility of
tissues in this region, it is still possible to rotate safely the flap up to 180
degrees.

PATIENT HISTORY AND PHYSICAL FINDINGS
■ The soft tissues making up the nasolabial fold and jowl area are lax and
mobile. Fortunately (from the reconstructive point of view), these qualities
increase with aging, when the need for flaps from this donor site also increases
to deal with surrounding defects created after tumor extirpation. The tissue
laxity facilitates primary repair of the donor site.
■ In addition, this area of the skin lies directly over the course of the facial artery
and its perforators, allowing for safe flap elevation and repair.
■ Superiorly and inferiorly based pedicled nasolabial flaps with a skin bridge
have been used successfully since ancient times. The inclusion of a skin bridge
makes the flap bulky, limits its mobility, and distorts the surrounding anatomy.
It also requires a secondary procedure to divide and inset the flap.
■ A better understanding of the anatomy of perforators refined and developed
island flaps supplied by one or more perforators devoid of skin bridge, which
has made it easier to rotate the flap and perform more one-stage
reconstructions.
■ Perforator flaps based on the facial artery can be considered for all substantial
defects of the perioral region, lips, distal nasal, and cheek (FIG 2).
■ They have the advantage of using local “like tissue” adjacent to the defect,
which results in aesthetically superior reconstructions. This includes the use of
hair-bearing skin from the jowl area for mustache and beard reconstruction.
■ As the facial artery is sandwiched between the superficial muscles of facial
expression and the deeper buccinator and mucosa (which are all supplied by
the facial artery), it is possible to raise a composite full-thickness cheek island
flap if this is what is needed for reconstruction.

FIG 2 • A. Patient with nostril sill and upper lip defect
after excision of basal cell carcinoma. B. Superiorly
based island perforator nasolabial flap. C. After single-
stage flap transfer.
■ To avoid injury to the muscles of facial expression, the deep part of this flap
can be harvested just inferior to the risorius muscle, where only the buccinator
muscle is taken with the flap (FIG 3).
IMAGING
■ A facial artery perforator flap is most often indicated for reconstruction after
tumor excision, and imaging may be required for oncological assessment to
ensure adequate resection. No special imaging is needed for operative
planning, however.
SURGICAL MANAGEMENT

Preoperative Planning
■ A careful diagnosis of the defect or deformity is required, and the suitability of
facial artery perforator flap is assessed. This will be made based on the
location, size, and depth of the defect as well as the subunits of the face, lip,
cheek, and nose involved.
■ Will a single facial artery perforator be adequate to complete the
reconstruction?
■ Is there adequate laxity in the surrounding tissues to allow closure of the
donor site with minimal deformity?
■ Can this be done in a single stage? If not, the patient needs to be counseled
about possible revisions and secondary procedures, especially if the defect
spans different subunits.
■ The integrity and location of the facial artery and its perforators are assessed
with a Doppler ultrasound.
■ There are multiple perforators along the course of the facial artery, but it is
best to choose the perforator closest to the defect to enable the flap to rotate
into the defect with the least tension.
■ Templates of the defect and subunits (using the contralateral side) are used to
design the flap, which usually abuts one edge of the defect (FIG 4). A piece of
sterile Esmarch bandage, aluminum foil, or DuoDerm can be used for the
template.
■ Such planning may lead to using other local flap rearrangement techniques to
reduce the overall size of the defect, especially if it encroaches several different
subunits.
■ These measures can result in a smaller perforator flap with fewer demands on
the donor site.
■ The greatest degree of laxity is in the lower cheek and jowl area, which is the
commonest site for flap harvest.
Positioning
■ Smaller defects can be performed under local anesthesia with sedation, but it is
more common to employ general anesthesia.
■ A nasal or oral endotracheal tube can be used. It is best to secure this with
suturing to the nasal septum or wiring to the dentition, to avoid tape and
distortion to the perioral area to better appreciate the entire operative field to
enable restoration of the best symmetry with the opposite side.