Geoffrey 3 C. Gurtner, Peter C. Neligan, Daniel Z. Liu – Plastic Surgery-Craniofacial, Head and Neck Surgery-Pediatric Plastic Surgery. 3-Elsevier (2018)

99.e1
Disorders of the scalp and forehead
A
B
Fig. 5.9  This series shows a 14-year-old girl who sustained a scalp avulsion injury of the temporal scalp (A) due to hair entanglement in a fan (B). The immediate result
post replantation is shown (C), as well as a later result with some, but incomplete hair growth (D).
C
D

100
SECTION II
CHAPTER 5 • Scalp and forehead reconstruction
A
B
C
D
E
F
G
H
I
J
Fig. 5.10  (a) Young male patient with extensive burn alopecia (A–C) with first round of expansion with two tissue expanders in right and left anterior temporal regions (D,
E). (b) Second round of tissue expansion in right and left posterior temporal regions (F–J).

101
Disorders of the scalp and forehead
Fig. 5.11  Frontal branch of facial nerve injury (A). Repair and functional recovery (B, C).
A
B
C
K
L
M
(c) Postoperative images after advancement of hair-bearing scalp to restore anterior and
posterior hairline (K–M).
Fig. 5.10, cont’d

102
SECTION II
CHAPTER 5 • Scalp and forehead reconstruction
Parry-Romberg syndrome where there is more widespread
atrophy involving hemiatrophy of one side of the face and
other parts of the body.38
If localized, an excision of indented scar, with local tissue
advancement, dermis-fat grafting, or structural fat grafting
may be used to repair the defect. Not uncommonly, there may
be poor “take” of the fat grafts, requiring repeat grafting.
Patients with larger deformities, as seen in Parry-Romberg
cases, may require free tissue transfers to adequately repair
the defect. Treatment is delayed until the condition has stabi-
lized (Fig. 5.12).39
Diagnoses and patient presentation
A thorough history and physical examination are critical, and
these should include relevant medical factors such as a history
of smoking, coronary artery disease, diabetes mellitus, radia-
tion, immunosuppression, and other medical conditions. The
etiology of the defect is also important with cases of malig-
nancy, and signs of local infiltration and regional and distal
metastasis must be investigated. The wound or defect needs
to be carefully analyzed in the context of the particular patient.
The surrounding tissues that may be utilized for repair should
also be evaluated.
Computed tomography (CT) scans, bone scans, MRI, and
positron emission tomography (PET) scans, may all be indi-
cated in selected patients. Incisional or excisional biopsies
may also be performed to assist in the diagnosis and planned
treatment. Sentinel node mapping of the head and neck may
also be indicated in management of patients with malig-
nancy.40,41 Thus, prior to commencement of treatment, a
comprehensive understanding of the cause of the wound or
defect, be it malignant or traumatic, is important in predicting
intraoperative defect size and to anticipate the natural history
of the underlying disease, and surgical management and
eventual prognosis for the patient.
Patient selection
There are many factors that need to be considered in develop-
ing a treatment plan for reconstructing scalp and forehead
defects. Table 5.1, modified from Temple and Ross’s original
publication, summarizes the factors important in defect
analysis.42
1.  The defect
An assessment of size, shape, orientation, and depth of the
defect are all important to consider, as these will determine
the amount of tissue needed for closure. The location of the
defect is also important. The parietal region of the scalp allows
the most advancement of scalp tissue, and defects in this
location are more amenable to scalp undermining and primary
closure. The occipital region has the least scalp mobility.
In cases of scalp lacerations, the depth of the wound is also
an important factor. The lacerations may be down to or
through the galea, and often it is the more superficial lacera-
tions with an intact galea that bleed more due to the rich
vascularity in the subcutaneous plane which may be stented
open by the intact galea. Bleeding can be quite excessive, and
this can be corrected by simply closing the wound with a
Other tumors
Most tumors of the scalp are of epithelial origin and include
basal cell30,31 and squamous cell cancers32,33 and melanoma.34,35
The treatment is the same as in other regions of the body,
and a detailed description of the pathology is covered in
other chapters. Of local importance is a knowledge of the
likely lymphatic spread from the scalp malignancies. These
are twofold: in the forehead and frontoparietal region,
the lymphatics drain to the superficial parotid gland and
retromandibular nodes. Posteriorly, the lesions drain to
the occipital nodes and occasionally the posterior triangle
cervical nodes.
Other primary tumors can arise from adnexal and con-
nective tissue elements and may be benign or malignant.
They include sarcomas (fibrosarcoma, dermatofibrosarcoma
protuberans, malignant fibrous histiocytoma, leiomyosar-
coma, rhabdomyosarcoma), cutaneous T-cell lymphoma, and
primary adnexal cancers.
Metastatic tumors to the scalp may also occur due to its
rich blood supply. These also occur in the underlying bone
and may expand and secondarily involve the skin. Meningio-
mas also may erode through the bony cortex.
Infections
Both localized and systemic infections can affect the scalp and
forehead. These may be due to bacterial, fungal, and viral
infections. Local wound care, drainage of abscesses, and
appropriate systemic antibiotics are the mainstay of treatment
of these conditions. These can all result in secondary scarring
and alopecia. The bacterial infections may result in folliculitis
which can become chronic, requiring excision and repair.
More severe infections including necrotizing fasciitis also
occur, though rarely. Appropriate treatment involves exten-
sive debridement, which results in extensive soft tissue deficits
requiring complex reconstructions.
Fungal infections, such as kerion and favus, are typically
managed by the dermatologist but can result in permanent
alopecia, which will be reconstructed by the plastic surgeon.
Kerion is the result of the host’s reaction to a fungal ringworm
infection (dermatophytosis) and appears as a thick mushy
area of the scalp, studded with pustules.36 Favus is a chronic
inflammatory dermatophytic (tinea capitis) infection usually
caused by Trichophyton schoenleinii, which results in the devel-
opment of a thick yellow crust (scutulum) around the hair
follicles. When this is removed, a moist erythematous base
results, and, with final healing, extensive scarring and alope-
cia results.37
Linear scleroderma (en coup de sabre) –
Parry-Romberg syndrome
En coup de sabre is a relatively common deformity seen in the
forehead and anterior scalp. It appears as a unilateral, verti-
cally orientated, indented linear atrophic deformity of the
skin of the forehead. It may start in childhood or adolescence
and is progressive for 3–5 years before it stabilizes. The etiol-
ogy is not known and is thought to represent an area of
localized scleroderma; the most widely accepted theory is that
it represents an autoimmune reaction to ectodermal deriva-
tives of the forehead and scalp. This may be associated with

103
Patient selection
Table 5.1  Consideration in defect analysis
Wound factors
Consideration
Location of the defect
Scalp
Forehead
Combined
Aesthetic subunits
Median/paramedian/lateral forehead
Temporal/parietal/occipital scalp
Exposed structures
Subcutaneous
Periosteum
Bone
Dura
Alloplasts
Surrounding soft tissue
Hairline position
Eyelids and brows
Pattern of baldness
Scars/previous procedures
Burns
Irradiation
Wound size
Small
Medium
Large
Contour
Dead space
A
B
C
Fig. 5.12  Young man with linear scleroderma of
the forehead and scalp (A). Management involved
de-epithelialization of depressed scar, leaving the
deeper dermal elements, with advancement of
adjacent normal forehead and scalp (B, C). The
scar at the junction between scalp and forehead is
broken up by a z-plasty. The immediate (D) and
later postoperative appearance (E) is shown.
D
E
full-thickness suture. If the galea is also lacerated, this is
included in the suture.
If skin grafting is contemplated, there has to be an intact
pericranium for adequate graft revascularization and take. In
defects involving the underlying bone, all exposed devital-
ized bone needs to be debrided before coverage. Exposed
dura usually requires some form of cranioplasty to protect the
underlying brain, and then coverage with a well vascularized
flap.
When selecting a flap for reconstruction, the size and loca-
tion of the defect will determine which local, regional, or free
flap will be required for initial reconstruction.
Ideally, it is also worth thinking ahead and envisioning
the best possible long-term aesthetic outcome. This is best
achieved by reconstruction with “like” tissue, as advocated
by Millard.43 In the scalp, restoration to “normal” involves
re-establishment of a hair-bearing scalp; in the adjacent fore-
head, a natural anterior and temporal hairline, and intact
uniform subunit without a “patchwork” effect of different
types of tissue reconstruction. With the forehead, it is also
important not to distort the surrounding mobile structures
such as the brow and eyelids. This may affect the initial flap
selection and also set in place staged secondary procedures to
maximize the aesthetic outcome.

104
SECTION II
CHAPTER 5 • Scalp and forehead reconstruction
2.  Vacuum-assisted closure (VAC)
The VAC system has emerged as a useful adjunct to the treat-
ment of difficult wounds. The wounds are first treated to
eliminate infection and all non-viable tissue is also debrided
until a clean wound results. The VAC can then be applied.
Although cumbersome, its use as a temporary dressing which
only needs changing every few days is very well tolerated and
appreciated by the patient. The VAC promotes healing and is
based on the application of negative pressure to the surface
of the wound which helps remove edema, increases the local
blood flow, and enhances granulation tissue and wound
healing. Intermittent or cyclical treatment appears to be more
effective than continuous therapy. The bacterial counts are
decreased with the use of a VAC (Fig. 5.13).45
The VAC system may be used to completion of healing or
as an adjunct to allow a clean granulating wound which can
accept a skin graft.46 However, care must be taken not to use
excess pressure which exceeds capillary closing pressure,
especially over bony surfaces, as this can result in ischemia of
the overlying periosteum. The VAC is also used as a dressing
after the application of a skin graft, as it has the benefit of
applying even and gentle pressure on the graft. However,
ensuring that this pressure is not excessive is again very
important to avoid not only graft loss but additional deeper
tissue necrosis.47
3.  Primary closure
Primary closure is possible for scalp defects up to a maximum
of 2–3 cm in diameter. Wide undermining of surrounding
scalp tissue is needed. Because of the rich vascularity, some
degree of tension is allowed. However, the galea is relatively
inelastic, and in order to allow primary closure, it is usually
necessary to utilize some scoring of the galea, but this should
be done carefully to avoid injury to the overlying blood
supply. Meticulous hemostasis after incisions of the galea is
also necessary.48
In the scalp, areas of alopecia may be treated with scalp
reduction techniques. This has been popularized by Unger,
and involves the excision of an ellipse of non-hair-bearing
skin, and wide undermining and advancement of normal
hairy scalp with a layered repair that includes the galea, to
minimize stretching of the scar.49,50
With the forehead, primary closure of defects should not
distort the surrounding mobile structures, especially the
eyebrows. Thus, for larger defects, it is mainly those that are
vertically oriented which can be closed in this manner.
4.  Tissue expansion
Tissue expansion is another very useful method of recon-
structing the scalp and forehead. This requires a staged
reconstruction where a silicon expander is placed beneath
adjacent healthy tissue. There is some connecting tubing to an
injection port, which is buried remotely from the expander (in
children this may be externalized), which is used to inject
fluid. Tissue expanders with integrated injection ports have
also been introduced recently.51–55
A small amount of fluid is injected at the time of insertion
of the expander to obliterate the dead space, and after a period
of healing which is usually 10–14 days, serial expansion
occurs to expand this normal tissue which can subsequently
2.  The surrounding tissues
The viability and quality of the surrounding tissues are
important. One should note the quality, thickness, and vascu-
larity of the tissues and the presence of scars from previous
operations. Prior injury, scars, and radiation damage may
diminish the availability of local flaps. All infections should
be controlled before attempts at wound closure with flaps or
the insertion of tissue expanders. Again, if possible, every
attempt should be made to minimize deformity of surround-
ing critical areas such as the hairline, which can be distorted
by excessive undermining and when designing rotation flaps
and planning scalp tissue expansion.
For oncological defects, clear margins of malignancy
need to be verified before reconstruction is commenced.
Local wound care or temporizing reconstruction with
allografts, xenografts, or dermal matrices is considered when
clear margins cannot be confirmed at the time of tumor
excision.
3.  Patient factors
Before considering complex reconstruction, it is important
to assess the patient’s overall health, level of function,
compliance, and personal preference. Patients with sig-
nificant comorbidities may not be candidates for lengthy
and multi-staged operative procedures. The oncological
patient needs special consideration. Attention should be
made to preoperative chemotherapy which may compromise
wound healing. Also, the nutritional state of the patient is
important.7,8
Treatment/surgical technique
A.  Reconstructive options – scalp and
forehead: common options
We will first consider simpler techniques that are applicable
to both scalp and forehead and then more specific local and
regional flap reconstructive options for these two sites and,
finally, reconstruction of more complex defects that often span
both sites, with free tissue transfers.
1.  Closure by secondary intention
Small defects may be allowed to heal by secondary intention.
In the scalp, this will result in a non-hair-bearing scar. In the
forehead, it is preferred to allow residual defects that cannot
be closed primarily (e.g., after use of a paramedian forehead
flap transfer for nasal reconstruction) to heal by secondary
intention. There is consensus that the resulting scar is superior
to that that would be obtained by the use of skin grafting. If
this method of reconstruction is adopted, daily dressing
changes with moist dressing is indicated until the wound
heals. Rarely, when the forehead donor site has not yet healed
at the completion of nasal reconstruction with a forehead flap,
the discarded skin from the pedicle of the forehead flap has
been used as a full-thickness graft of the forehead defect, with
satisfactory results, which is not surprising as it is a repair
with like tissue.44

105
Treatment/surgical technique
A
B
C
Fig. 5.13  Elderly patient with post traumatic injury
to scalp with exposed central cranial bone devoid
of periosteum (A). The initial treatment was with a
VAC dressing (B). Later, a large axial bipedicle
flap, based on right and left superficial temporal
arteries, is raised and used to cover the exposed
bone (C). The flap is split diagonally and moved
sagittally to cover all the exposed ungraftable bone
(D). The resulting donor defect if skin grafted. The
final appearance is shown (E).
D
E
be used to reconstruct adjacent scarred areas. This technique
cannot be used acutely, when there are any open wounds or
any evidence of infection. The proposed flap design should
be mapped out prior to placement of the tissue expander.55
The best results are obtained with transposition or rotation
flaps, rather than simple advancement flaps. It typically takes
2–3 months to expand the tissue sufficiently to perform the
reconstruction (Figs. 5.8, 5.10, 5.14).
Tissue expansion of the scalp and forehead is not without
its problems. Complication rates as high as 48% have
been described. Common complications include hematoma,
implant exposure, infection, flap necrosis, alopecia, and
widened scars. Prior to cranial suture fusion, pressure from
the expander may deform the underlying skull. The simulta-
neous use of multiple expanders can increase the complication
rate via vascular compromise of the skin/scalp envelope. In
addition, careful planning of expander position avoiding
external pressure when sleeping will decrease the likelihood
of extrusion and other complications.56,57
4.  Skin grafts
Primary split-thickness and full-thickness skin grafting can be
used as an expeditious way of closing a wound, especially in
a compromised patient. After tumor excision where the risk
of recurrence is high, this may also be elected so that the
wound could be better monitored. For skin graft to be effec-
tive, a vascularized bed is required. If there is exposed bone,
this will usually need a flap repair. Alternatively, multiple
drill holes can be done through the outer cortex down to the
diploic layer and then await full granulation of tissue to
occur.58 Caution should be used in cases of malignancy, espe-
cially in recurred tumors and in irradiated beds, as drilling
the outer cortex can potentially implant malignant cells into
the bone and dura. The authors have seen this complication
and strongly advise against the use of drilling the bone in
these cases.
The use of a VAC dressing in these situations assists with
the development of the granulation tissue and subsequent
wound coverage with the skin graft.
The advantage of skin grafting is that it is fairly simple;
however, the disadvantage is that this is not hair-bearing in
scalp reconstructions. In the forehead, a skin graft lacks the
normal color, texture of the surrounding tissue, and it fails to
restore the contour and results in a non-aesthetic patchwork
appearance.
The other options of reconstruction, namely local, regional,
and free flaps will be discussed separately for the scalp
and forehead as there are different options and goals of
reconstruction.
B.  Reconstructive options – scalp: local and
regional flap reconstruction
Leedy et al. have developed a very useful algorithm for recon-
struction of acquired scalp defects, to achieve not only wound
closure but also an aesthetically optimal result.59

106
SECTION II
CHAPTER 5 • Scalp and forehead reconstruction
the central scalp with hair-bearing flaps. Every attempt is
made to make these flaps axial to ensure better perfusion
(Fig. 5.19).60–63
We find that the use of templates and simulated transfer is
invaluable in flap design – this results in a flap that would
appear at first glance to be larger than required, but due to
the factor of skull curvature, it ends up being just right.
The use of hair-bearing flaps, such as the Juri flap, has been
described to reconstruct the anterior hairline.64,65 This flap is
based on the posterior parietal branch of the superficial tem-
poral artery and typically, because long hair-bearing flaps are
needed to restore the hairline, it is safer to delay this flap.66
For very long flaps, two preliminary delay procedures may
be required, prior to flap transfer (Figs. 5.20 & 5.21). A disad-
vantage of the Juri flap is that it alters the natural direction of
hair growth, as the hair grows directly upward, whereas
normal anterior hair growth is in a downward direction. To
correct this, a transfer of the Juri flap as a free flap and anas-
tomosed to the contralateral temporal vessels has been per-
formed to maximize the aesthetic appearance.
Scalp flaps are elevated at the subgaleal level, preserving
the underlying periosteum to allow skin grafting of the result-
ing secondary defect. A dog ear deformity is common at the
flap pivot point, again accentuated by the underling rigid
skull curvature. It is best not to deal with this acutely as it can
impact on the vascularity and typically settles down or can
be easily corrected secondarily. It is also important to avoid
too much tension, as this can result in alopecia. Alopecia also
Local flaps
Fig. 5.15 concisely illustrates the different local flap options
that are commonly used in scalp (and forehead) reconstruc-
tion. The immediate surrounding tissue is used for small to
medium defects. The flaps move by rotation, transposition,
and advancement, and commonly all three elements factor in
tissue movement. Small pin wheel flaps (two-flap “ying-
yang”, and three-flap “Isle-of-Man”) are commonly used for
small defects (Figs. 5.15–5.17). Larger rotation flaps with judi-
cious back cuts may also be used. For longitudinal defects,
bipedicle transposition flaps may be used. Unlike other parts
of the body where the secondary defect can generally be
closed, this is not the case in the scalp, as usually the curved
surface and tautness of tissue make it necessary to skin graft
the resulting donor defects (Fig. 5.18
).
Fig. 5.18 appears online only.
In designing flaps, the possibility of making them axial,
with a known dominant vascular pedicle traversing the
length of the flap, ensures greater safety and avoids distal
tip necrosis (which is usually the most critical part of the flap
needed for repair) which can lead to overall failure of the entire
reconstruction (Fig. 5.18). The Doppler ultrasound is routinely
used to map out the main vascular blood supply. In general,
it is safer to use large and longer flaps and to carefully plan
the reconstruction to account for the curvature of the scalp.
Orticochea was one of the first to propose the use of multiple
large flaps, extensively mobilized to close large defects in
A
B
C
Fig. 5.14  Tissue expansion: patient with prior excision of dermatofibrosarcoma protuberans (DFSP), requiring wider excision and additional skin grafting (A). Two
crescentic tissue expanders were inserted (B), slowly inflated over 6 weeks (C), and eventually used to cover the defect after excision of the skin graft (D, E), achieving full
hair restoration (F).
D
E
F

106.e1
Treatment/surgical technique
A
B
C
Fig. 5.18  Seventy-year-old man with area of post irradiation necrosis of posterior scalp with exposed bone (A).
An axial musculocutaneous flap based on the occipital artery is designed (B) and transposed to cover the defect
(C). The resulting donor site is skin grafted. The long-term result with good hair growth is shown (D).
D

107
Treatment/surgical technique
A
B
C
D
E
F
Fig. 5.15  Local scalp flaps. (A, B) scalp rotation flaps; (C) pinwheel flap; (D) bipedicle advancement flaps; (E) double opposing rotation flaps; (F) Y to T flap;
(G) bipedicled fronto-occipital flap. (Reproduced from Marchac D. Deformities of the forehead, scalp, and cranial vault. In: McCarthy JG (ed). Plastic Surgery. Philadelphia:
WB Saunders; 1990:1538.)
G
occurs along suture lines and may require secondary
revision.
Component separation of the scalp, typically with the use
of separate galeal flaps for defects created by neurosurgical
and craniofacial approaches, is another useful option in the
surgeon’s armamentarium. This is most commonly used in
the frontal area, where the galea and attached frontalis muscle
is often used to repair frontal sinus and anterior cranial
defects.67
The temporoparietal fascial flap based on the superficial
temporal vessels has been previously mentioned for its use in
ear and orbital reconstruction.68,69

108
SECTION II
CHAPTER 5 • Scalp and forehead reconstruction
C.  Reconstructive options – forehead: local
and regional flap reconstruction
The forehead makes up the upper third of the face and is
important for facial aesthetics. Scarring in the uppermost part
of the forehead can be partially hidden with appropriate hair
styling. In the central and lower forehead, scars that are
aligned and parallel to the transverse crease lines (produced
by frontalis muscle contraction) fade and become less notice-
able with time. In the lower, central part of the forehead, verti-
cally oriented scars also align themselves with the natural
creases due to the action of the underlying corrugator and
procerus muscles, and with time become less noticeable.
However, wounds and defects can be at many different
sites, have different orientations and shapes, and repair results
in scars that are not in the “ideal” location. It is far more
important that the repair does not distort the mobile structures
at the lower border of the forehead and the hairline laterally,
as these scars also fade with time and become less noticeable,
whereas a displaced landmark will create a persistent defor-
mity. In general, preservation of normal contour and normal
landmarks is far more important than the associated scar, and
this should be one of the main guiding principles in selecting
the most appropriate method of repair of forehead defects.
As discussed earlier, although the forehead appears to be
a single subunit, more careful analysis, based firstly on the
regional blood supply and secondly on the variations in tissue
mobility and the degree of tautness of the different parts,
makes it more practical to subdivide the forehead into smaller
subunits, as first proposed by Ian Jackson and modified
slightly by the current authors. These subdivisions allow a
better algorithmic approach in flap selection.
With respect to the blood supply, the forehead has a very
rich and unique blood supply with a rich interconnection
between branches from the internal carotid and external
carotid systems. Centrally, there are two paired, vertically
orientated supraorbital and supratrochlear vessels from the
internal carotid and, laterally, the transversely running ante-
rior branch of the superficial temporal vessels, from the
external carotid system. The resulting rich vascular plexus
makes it possible to raise the entire forehead on any of these
vessels. This has enabled the forehead to be an extremely
useful donor site for reconstructing adjacent tissues outside
the forehead, especially for nasal reconstruction and less often
cheek, eyelid, palate, and intraoral reconstruction. As the
focus of the current chapter is forehead reconstruction, we
will focus on how best to use similar axial flaps to close
various defects within the forehead.
With respect of the tissue mobility and tautness, the central
part of the forehead is tighter and has less subcutaneous tissue
than the tissue in the temporal area and glabella and supra-
brow area. The most mobile is the glabella and suprabrow
region, where in addition to extra subcutaneous tissue there
are also corrugator and procerus muscles, which add to the
mobility at these sites. These regional variations help dictate
the selection of flaps used for repair. Thus, whereas VY-type
advancement flaps work well in the mobile areas of the gla-
bella, suprabrow, and temporal areas, they are not effective in
the central forehead and, if used, partial or total necrosis can
result.
The following is our algorithmic approach of reconstruc-
tion of forehead defects with local flaps:
Regional flaps
There are very few regional flaps available for scalp recon-
struction. One exception is the trapezius myocutaneous flap,
based on the transverse or descending branch of the transverse
cervical vascular pedicle.70 This may be considered for post
auricular and posterior scalp defects, as the maximum reach
is to the upper occipital area. Care must be taken to preserve
the accessory nerve supply to the upper part of the muscle to
prevent shoulder droop (Fig. 5.22).71
The latissimus dorsi, pectoralis myocutaneous, and ex­
tended submental platysma myocutaneous pedicle flaps
have also been described for repair of defects of the temporal,
post auricular, and most peripheral scalp defects but are
seldom used, as the most distal parts of these flaps (with
the poorest blood supply) are the parts crucial for repair,
and failure commonly ensues.72 The latissimus flap is much
more commonly used as a free flap, which is described
below.
A
Fig. 5.16  Repair of small scalp defect with exposed bone with “ying-yang” flaps.
B

109
Treatment/surgical technique
flap on top of the advancement VY component. If this trans-
position component is hair-bearing, it will result in some
alteration in direction of hair growth (Fig. 5.25B). Large trans-
position, rhomboid, or bilobed flaps tend to distort the natural
landmarks and are not recommended.
Fig. 5.25A,B appears online only.
2.  Suprabrow and glabella subunits
This tissue is even more mobile than the lateral subunit, and
for this reason advancement flaps work very well. Again, it is
important not to distort the brow, so the VY flap is designed
just above the brow, and it is moved based on its subcutane-
ous tissue. Double opposing VY flaps can also be used for
larger defects (Fig. 5.26
).
Fig. 5.26 appears online only.
1.  Temporal subunit
The mobility of tissues in this subunit is due to a relative
increase of subcutaneous tissue, and this applies both to the
hair-bearing temporal scalp and hairless forehead skin ante-
riorly that forms the lateral part of the forehead. The blood
supply is rich and comes from the superficial temporal vessels.
Advancement flaps that do not distort the surrounding tissues
work best: VY (Fig. 5.23A,B), extended VY, and double
extended VY flaps have all been used effectively (Fig. 5.24).73
These flaps can be designed to move both hair-bearing and
non-hair-bearing tissues as part of the same advancement
flap (Fig. 5.25A,B). The advancement is usually in vertical or
obliquely upward or forward direction, thus causing minimal
distortion of the tissues. When advancing extended type VY
flaps, the extended part of the flap moves as a transposition
Fig. 5.17  Repair of small scalp defect with triple pin-wheel (“Isle-of-Man”) flaps.
Incision
Incision
Incision
Suture
Suture
Suture
A
B
C

109.e1
Treatment/surgical technique
A
B
C
Fig. 5.25  (A) Fifty-three-year-old man with defect in the hair bearing temporal region after resection of choroid syringoma. (B) Repaired with extended V to Y hair bearing
flap. (C) Long-term follow-up one year after reconstruction. (D) Nineteen-year-old man with granuloma and defect of temporal forehead. (E) Repaired with extended hair
bearing V to Y flap. (F) Follow-up 3 months after repair, note the change in the direction of the hair.
D
E
F
Fig. 5.26  Glabella–suprabrow defect: patient with glabella defect post excision of sebaceous hyperplasia, repaired with bilateral VY advancement flaps, without distortion of
natural eyebrow landmarks.
A
B
C

110
SECTION II
CHAPTER 5 • Scalp and forehead reconstruction
usually very easy to close this inferiorly, but there is more
tension superiorly (Fig. 5.28).
Larger vertically oriented defects are repaired by bilateral
forehead (+/− and scalp) flap mobilization, with galeal scoring
and back cut if needed and results in a central vertical scar
(Fig. 5.29).
For central defects that are more transversely orientated, a
paramedian transposition flap is used, as any attempt to
directly close this would result in an upward pull of the brow
(Fig. 5.28). Any smaller areas that cannot be closed after flap
transfer can be repaired with a full-thickness skin graft that is
harvested as part of a dog ear excision as part of flap mobiliza-
tion or allowed to heal by secondary intention. Larger skin
grafted areas are cosmetically and functionally suboptimal
(Fig. 5.30A). The skin grafted part is depressed, pale, and
shiny and potentially liable to breakdown. The skin graft can
be excised by serial excision or with the assistance of tissue
expansion (Fig. 5.30A,B).
With even larger central defects also involving the glabella
area, the repair with local tissue versus free tissue transfer
needs to be carefully evaluated. If possible, the use of large
Larger defects of the medial suprabrow area require a verti-
cally oriented transposition flap, which can be raised from the
adjacent glabella. This glabella flap is based on the terminal
branches of the angular vessels (Fig. 5.27).
For larger defects where the glabella is missing, a parame-
dian forehead flap based on the supratrochlear vessels may
be used (Fig. 5.28). All these strategies effectively move “like”
tissue into the defect and cause minimal distortion to the
brow.
3.  General forehead
It is best to divide the main body of the forehead into (a)
central and (b) lateral. The central part is supplied by the
supratrochlear and supraorbital vessels, and the lateral part
by the watershed area between the temporal and supraorbital
vessels.
3(a). Central
Narrow, central, vertically oriented defects, as seen after a
paramedian forehead flap transfer, are closed vertically. It is
Fig. 5.19  Orticochea three-flap technique. Two flaps based on the superficial temporal artery are used to reconstruct the defect. A posterior-based flap based on the
occipital vessels is used to fill the donor defect. (Reproduced from Arnold PG, Rangarathnam CS. Multiple flap scalp reconstruction: Orticochea revisited. Plast Reconstr
Surg. 1982;69:607.)
Occipital vessels
Galea
Skin graft
Incisions
Pericranium
remains
Bone skull
1
1
1
1
1
2
2
2
2
2
3
3
3
3

111
Treatment/surgical technique
local transposition and advancement flaps is preferred, as the
result will have a better color, contour, and texture match than
what can be achieved with free tissue transfer. Fig. 5.31 illus-
trates the use of an extended forehead/scalp flap based on the
anterior branch of the superficial temporal artery which is
advanced, and the distal part is transposed to close this
extensive post Mohs excision of a basal cell carcinoma (BCC).
Additionally, a superiorly based nasolabial flap is used to
repair the glabella area, with the transfer of part of the beard
area which is used to repair the missing medial eyebrow. The
postoperative photograph shows the end result after thinning
and revision of the nasolabial flap and it also shows good hair
growth of the eyebrow reconstruction.
3(b). Lateral
Small defects can be closed by lateral advancement flaps that
do not distort the eyebrow and upper eyelid. Larger defects
are repaired by large axial rotation/advancement flaps based
on the supraorbital and supratrochlear vessels (Fig. 5.32). The
resulting secondary defect, although often depicted in line
drawings as closing primarily, usually needs a skin graft. This
can be later removed serially or with the aid of tissue
expansion.
Fig. 5.20  The Juri flap. After two preliminary delay procedures (A), a
temporoparieto-occipital flap is elevated (B) and used to reconstruct defects in the
anterior hairline (C).
A
B
C
Fig. 5.21  Ten-year-old boy with burn alopecia
involving the anterior hairline, repaired with a Juri flap
and full-thickness skin graft to the forehead.
A
superficial
temporal
artery
B
C
D
E

112
SECTION II
CHAPTER 5 • Scalp and forehead reconstruction
A
B
C
Fig. 5.22  Elderly man with post irradiation necrosis of the posterior scalp (A). The area is debrided (B) and a pedicled trapezius myocutaneous flap is designed (C), raised
(D), and transferred to repair the defect (E). The postoperative appearance and ability to shrug shoulders (due to preservation of the accessory nerve) is shown (F).
D
E
F
A
B
C
Fig. 5.23  (A) Temporal subunit of forehead: Male patient with BCC excised and repaired with VY advancement flap, moved superiorly from upper cheek. (B) Temporal
subunit of forehead: VY flap from lateral forehead to repair defect after BCC removed. (C) Sixty-one-year-old female with temporal region basal cell carcinoma.

113
Treatment/surgical technique
D.  Microsurgical reconstruction with
free flaps
Large complex defects, with exposed vital structures, are best
repaired with free tissue transfers. The reported success rate,
even in debilitated and elderly, is in excess of 95%. Histori-
cally, the first described scalp reconstruction with a free flap
was by McLean and Buncke who used a free omental flap.74
This provided a well vascularized bed that covered all vital
structures and could accept a skin graft. Free omental flaps
are not commonly used for scalp reconstruction today, as they
are relatively thin, may not restore the contour, and have
greater morbidity as they require an intra-abdominal approach
for harvest.75,76 Also, with the renaissance in the study of the
vascular anatomy of the skin and muscles that followed this
early free flap transfer, there are now many more options to
the reconstructive surgeon.77 The focus has shifted from
obtaining flap survival using a limited number of flaps, to
better flap selection and refinements. Refinements are achieved
by careful preoperative and intra-operative assessment of the
defect, determining the reconstructive requirements, and then
selecting the best donor tissue that gives the best functional
and aesthetic result.
The mainstays of free flaps used for scalp reconstruction
are muscle, musculocutaneous and, to a lesser extent, fascio-
cutaneous flaps, which are more commonly used for forehead
reconstructions. Each has its merits and indications, and the
choice of a particular method of free flap depends on the
E
F
D
Fig. 5.23, cont’d (D) Design of resection and hairless
extended V to Y advancement flap. (E) Immediate
postoperative result after advancement flap and closure.  
(F) 3 month follow-up after excision and closure of temporal
subunit reconstruction.

114
SECTION II
CHAPTER 5 • Scalp and forehead reconstruction
are close to the scalp and forehead. However, these vessels
may be unsatisfactory due to prior injury at the time of
ablative surgery or secondary to the effects of irradiation.
Although the artery, especially with proximal dissection into
the parotid, is usually of adequate caliber, the veins may be
small, thin-walled, and fragile. It is best to perform the anas-
tomoses of artery and vein at a similar location to prevent
twisting and misalignment of the pedicle. Thus, the surgeon
must be prepared to extend the dissection into the neck and
isolate other branches of the external carotid system (or the
external carotid itself), and adjacent veins which drain into
the external or internal jugular systems. The division of the
posterior belly of the digastric may facilitate the dissection of
the recipient arteries.
defect size, wound condition, availability, recipient vessels, as
well as surgeon and patient preference (Figs. 5.33 & 5.34).
Recipient vessels
The recipient vessels utilized in both scalp and forehead free
flap reconstructions are similar.78–80
Ideally, the recipient vessels should be of adequate
caliber, be outside of the zone of injury, yet close enough
to allow a primary anastomosis. Unfortunately in scalp and
forehead reconstruction, there is a paucity of vessels close
to the defect, and the next group of available vessels is at
a distance which often necessitates the use of vein grafts.
The superficial temporal vessels are the only vessels that
A
Fig. 5.24  Design of extended and double extended VY flaps for use in the temporal area. These may be used to repair defects that are both hair-bearing and hairless, with
appropriate design of the extended part(s) according to hair need, with the goal to preserve the normal hairline. (Adapted from Pribaz JJ, Chester C, Barrall DT. The extended
V-Y Flap. Plast Reconstr Surg. 1992;90:275–80.)
B

115
Treatment/surgical technique
In extreme cases, where the neck has had prior radical
lymphatic dissection and damaged by irradiation, so that it is
“frozen”, the choice of recipient vessels becomes more diffi-
cult. These patients may already have had a prior free flap,
and it may be possible to utilize this flap’s pedicle for the new
flap.84–86 Alternatively, to get outside of the zone of injury, the
strategies may include the use of vessels on the contralateral
neck, or the transverse cervical vessels (branches of the thy-
rocervical trunk) in the supraclavicular area.79–81 The use of
these distant vascular sources makes the use of long vein
grafts or arteriovenous loops mandatory. Rarely, or in salvage
situations, where there are no veins, the use of the cephalic
vein may be considered. This is located in the deltopectoral
groove and dissected down into the arm, and rotated superi-
orly to the neck.87
Flap selection
Appropriate flap selection will depend on the location,
size of the defect, desired pedicle length, intraoperative
positioning of the patient, initial and final goals of recon-
Although there are more choices of recipient vessels in the
neck, the longer distance to the defect is addressed by selec-
tion of a flap with a longer pedicle or the use of vein grafts.81
As both the artery and vein need a bridging graft, the use of
an arteriovenous loop is the usual way of resolving this
problem.82 It is best to plan this as part of the reconstruction
rather than scrambling after the free flap is detached to mini-
mize ischemia time (Fig. 5.33).
Occasionally, the occipital artery may be utilized as the
recipient vessel for reconstruction of posterior scalp defects.
An end-to-end repair of artery and vein is the most common
method of repair, although if larger veins, such as the external
or internal jugular, are selected as recipient vessels, then an
end-to-side repair may be utilized. Some authors believe that
the higher negative pressure within the internal jugular vein
that occurs because inspiration “sucks” blood out of the flap
and decreases the chance of venous thrombosis. Chalian et al.
compared free flap failures when using the internal jugular
versus branches of the external jugular vein and found a
reduced thrombosis risk when the internal jugular was used
(1% versus 8% in 156 free flaps).83
A
Fig. 5.27  Glabella–suprabrow defect: patient with larger defect in glabella/brow
area, repaired with a vertically oriented glabella flap based on the terminal branches
of the angular artery to repair a transversely oriented defect.
B
A
Fig. 5.28  Central forehead: patient with central, transversely oriented forehead
defect post melanoma excision and repaired with a vertically oriented paramedian
forehead flap which avoids distortion of natural landmarks, like the eyebrows.
B

116
SECTION II
CHAPTER 5 • Scalp and forehead reconstruction
For larger defects, the latissimus dorsi plus the serratus
anterior, plus an anterior skin island, (extending beyond the
anterior edge of the latissimus dorsi muscle but still based on
anterior perforators from the thoracodorsal vessels) may be
used. For total scalp defects, bilateral latissimus dorsi muscle
free flaps may be required.
In most cases, the authors prefer to take a skin island with
the latissimus dorsi flap (i.e., a myocutaneous latissimus
dorsi flap) for several reasons: the skin island makes it easier
to monitor the flap, creates a minimal donor site defect, and
minimizes the skin graft requirements. Also, if it is planned
to eventually expand the adjacent hair-bearing scalp and
restore the hairline, it is preferable to suture the advancing
scalp flaps to skin rather than skin grafted muscle. Admit-
tedly, the thickness of the skin island is greater than the
thickness of the scalp; this can be easily thinned subsequently
or during the scalp hair-restoration phase.
Other muscle and myocutaneous flaps including the rectus
abdominus flap are also commonly used, due to their ease of
elevation remotely from the head and neck, allowing a two-
team approach. Although it is a much thicker flap, this may
sometimes be indicated in reconstructing compound defects
where the calvarium has been removed and additional bulk
is need to restore the contour (Fig. 5.8). This flap also has a
long pedicle, which can be even longer if elevated as a deep
inferior epigastric perforator (DIEP) flap.96
Fasciocutaneous flaps are especially indicated for recon-
struction of larger forehead defects. If a free flap is contem-
plated for the forehead, the subunit principle of replacing the
entire subunit gives the best cosmetic outcome (Fig. 5.33).
Fasciocutaneous flaps may also be considered for scalp recon-
struction if the eventual goal is restoration of hair-bearing
scalp for, as mentioned above, it is easier to perform staged
tissue expansion and suture of hair-bearing scalp flaps to skin
rather than skin grafts (Fig. 5.8).
The most commonly used flaps include radial forearm,97,98
scapular and parascapular,99 and anterolateral thigh (ALT)
fasciocutaneous flaps.100–104 All these flaps are hardy, easy to
raise, and have relatively long vascular pedicles (Figs. 5.33 &
5.34).
Both the radial forearm and ALT have the benefit of being
remote from the head and neck facilitating a more expeditious
two-team surgery. The approach to the scapula and para-
scapular flap harvest is similar to the latissimus dorsi and may
involve position changes intra-operatively.
Although in the past many have listed numerous potential
disadvantages of free tissue transfers, focusing on the length
of operation and anesthetic, the fact that it is technically
demanding, costly, and has a risk of flap failure, there is no
doubt that when indicated this is the best way of solving
problems. Also, today, most graduates of our training pro-
grams have had an extensive exposure to free tissue transfers
and the reported outcomes show, in fact, a high success rate
even in patients with advanced disease.90,91,93,105
Face transplantation
Despite all the advances that have occurred in reconstruc-
tive surgery over the last 30–40 years, the ability to restore
severely damaged parts back to “normal” have been elusive.
There is no way, for instance, to restore a normal hair-bearing
scalp if the entire scalp has been lost and is not available
struction, and surgeon’s experience and familiarity with a
particular flap.88–93
With respect to location, for scalp reconstruction, a muscle
or myocutaneous flap is more commonly used; for the fore-
head, it is preferable to utilize a fasciocutaneous flap.
By far the most common muscle flap used in scalp recon-
struction is the latissimus dorsi muscle flap, based on the
thoracodorsal pedicle. It has the advantages of a relatively
long and reliable vascular pedicle, and it is large and can
cover extensive scalp defects. The muscle is skin grafted and
will undergo atrophy over time, resulting in a soft tissue
thickness that closely resembles the native scalp. A fenestrated,
unmeshed graft which is typically quilted onto the underlying
muscle gives a superior and more uniform appearance than
a meshed graft (Fig. 5.33).94,95
For smaller defects, a tailored smaller latissimus muscle
may be harvested or, alternatively, the lower three or four
slips of the serratus anterior muscle based on the same (and
even longer thoracodorsal) pedicle may be used. The use of
only the lower part of the serratus muscle avoids winging of
the scapula.
A
Fig. 5.29  Central forehead: patient with a central, vertically oriented forehead
defect post Moh’s excision of BCC, repaired with bilateral advancement forehead
flaps, with back cuts and galeal scoring.
B

117
Treatment/surgical technique
A
B
C
D
E
F
G
H
I
Fig. 5.30  (A) A fifty-nine year old patient with a large central forehead deformity repaired
with a skin graft post excision of a DFSP. (B, C, D) Preoperative, intraoperative and
postoperative pictures of the first stage of serial excision. (E,F) 6 months later the
remainder of the skin graft was excised. (G,H) Early postoperative results showing intact
frontalis muscle function after forehead continuity was reestablished. (I,J) Again a few
months later, a minor scar revision of the forehead and a w-plasty of the scalp were
performed to correct an area of scar alopecia.
J

118
SECTION II
CHAPTER 5 • Scalp and forehead reconstruction
axial angiosome.110 In this case, the axial facial angiosome
adequately perfuses the next angiosome – namely forehead,
maxilla, mandible, and neck. This has been confirmed in our
dissection studies and clinical outcomes in our cases. We do
not know how much of the scalp can be successfully trans-
ferred based on only the facial blood supply, but certainly the
anterior 5–6 cm can. We would predict that the superficial
temporal vascular supply would be needed for transfer of
larger/total scalp transfers.
Postoperative care
The postoperative management will depend on the condition
treated and the type of treatment rendered.
The use of antibiotics also depends on the nature of the
problem, but if used prophylactically, they are just adminis-
tered perioperatively. Patients with infective processes, com-
promised wounds, exposed dura, or where foreign material
and grafts have been used, are treated with a full course of
antibiotics.
Defects that are allowed to close by secondary intention
will need local wound care until healed.
for replantation.106,107 In recent years, the advent of com-
posite tissue transplantation for management of complex
facial deformities has provided a new and exciting option
for the ultimate reconstruction of “like” with “like”. In
fact, it has added a new rung to the reconstructive ladder.
With transplantation of the face we have seen a shift in
paradigm of repair from the concept of “reconstruction” to
“restoration”.
In our unit, we have successfully performed seven face
transplants to date, and four have included the forehead and
two of these also included the anterior scalp.108,109 All of our
cases have been transferred based on the facial vessels alone,
and yet there was adequate perfusion of the forehead and
anterior scalp (as well as the lateral cheek, maxilla, anterior
mandible, and neck in our other cases). In our cases, the
forehead and anterior scalp did not have a direct axial blood
supply but were perfused by connections between the termi-
nal branches of the facial artery and periorbital vessels (Fig.
5.35). The blood supply has been adequate to allow long-term
normal appearance and normal hair growth in the transferred
scalp. This can be understood by applying Taylor et al.’s
angiosome concept, which predicts that one can successfully
transfer the next adjoining angiosome to that of the primary
A
B
C
Fig. 5.31  Complex defects involving multiple parts of the forehead subunit: a patient with a very extensive central forehead, suprabrow, glabella, and medial eyebrow defect
post Moh’s excision of a BCC. The defect was repaired with a large scalp/forehead transposition-advancement flap plus a nasolabial flap (to reconstruct the glabella and
eyebrow with hair from the nasolabial area). The final appearance post division, inset, and debulking of the nasolabial flap is shown.
D
E
F

119
Outcome, prognosis, and complications
Free flaps need the same precautions as listed above and,
in addition, close monitoring to detect vascular thrombosis.
This is done with frequent monitoring of the flap’s color and
capillary return, the use of an external Doppler and by the
use of implantable devices, such as a Cook catheter (Cook
Medical) or tissue oximetry using near-infrared spectroscopy
(ViOptix).112 Skin grafted free muscle flaps are frequently
used for scalp reconstruction, and these are more difficult to
monitor clinically than flaps which also have a skin island,
and it is safest to include an implantable Doppler device in
these patients.
Outcome, prognosis, and complications
■ Wound dehiscence, especially in the setting of tighter
closure prevalent in scalp and forehead repairs, can occur
following any procedure. These are treated with local
wound care, debridement as needed and, once stabilized,
secondary repair.
■ Postoperative wound infections may also occur,
especially when dealing with compromised tissue such as
irradiated wounds. However, due to the robust blood
supply of the scalp and forehead, infections are relatively
less common than in other parts of the body. Antibiotic
prophylaxis for problem wounds, and treatment with
Skin grafts are immobilized by tie-over bolster dressings or
by a VAC device; with both, it is essential that excess pressure
is not applied, as this can lead to graft loss and necrosis of
underlying previously vascularized tissue, which will result
in a wound which will need a more complex method of repair.
The bolster or VAC is removed at 5–6 days (Fig. 5.13).
When tissue expanders are used, the expander is partially
inflated to obliterate the dead space, and typically a drain is
also inserted to avoid seroma due to wide dissection and
undermining. The drain is usually removed after a few days.
The expansion process begins about 10–14 days later, placing
small amounts into the injection port every week or twice
weekly as tolerated by patient and the tissues. It typically
takes at least 8 weeks until adequate tissue has been recruited.
It is important that the injection port is at a distance from the
tissue expander so that the expander is not damaged by injec-
tions as it expands. An alternative is to have an integrated
port, or an exteriorized port, which some surgeons use in
pediatric patients, where often the parents are taught to do
the expansion.
Local and regional flaps are monitored for their vascularity
and protected from direct pressure, which can be difficult in
certain locations, especially over the occiput. Occasionally, a
temporary halo device may be needed to keep pressure off a
vital flap.111 These patients also have skin-grafted secondary
donor site defects which need care as described above.
A
B
C
Fig. 5.32  Lateral forehead defect: a 92-year-old patient with a large extensive radionecrotic right forehead/scalp defect post excision of prior BCCs and SCCs. The patient
has previously had 11 procedures in attempts to close the wound, including skin grafts, Integra, VAC dressing, hyperbaric oxygen therapy, etc., which all failed. The wound
was debrided and margins checked for malignancy. A large axial extended forehead flap, based on the supratrochlear and supraorbital vessels is raised and transferred to
repair the defect, and the resulting secondary donor site is skin grafted. The long-term postoperative result is shown.
D
E
F

120
SECTION II
CHAPTER 5 • Scalp and forehead reconstruction
A
B
C
D
E
F
G
Fig. 5.33  (A) This renal transplant patient has an aggressive SCC involving forehead, frontal sinus, inner table of calvarium left orbit. (B) This was radically excised with
neurosurgery and craniofacial surgery leaving a large frontal bone, orbital roof boney defect and significant soft tissue defect. (C) Cranial protection was obtained with
titanium mesh for both the orbital roof/skull base and frontal bone deficit and a latissimus dorsi flap with a skin graft was used for soft tissue coverage. (D) The healed
forehead with skin grafted latissimus flap is shown. (E) 6 Months after radiation therapy was completed further surgery to improve the appearance was planned. (F)
Operative planning involved a template and (G) the entire forehead subunit was de-epithelialized in preparation for forehead soft tissue replacement.

121
Outcome, prognosis, and complications
this occurs in the later part of the process, the second
stage can be expedited, and expander removed and
expanded flap transferred. If exposure or infection occurs
before adequate expansion has occurred, the expander
will need to be removed, antibiotics administered, and
the wound allowed to heal for several months before
re-expansion can be repeated.
■ Complications tend to be more common if multiple
expanders are used, and part of the problem may be
related to external pressure effects with sleeping, etc. We
typically do not use more than two expanders at the
same time.
■ Failure of skin grafts can result from the usual causes
such as hematoma, infection, and mechanical effects of
sheering, and appropriate measures to minimize these
possibilities should be taken. However, in the scalp,
probably the commonest cause is a poorly vascularized
bed. This can be improved with the initial use of a VAC
device to stimulate granulation and other techniques,
such as drilling the outer cortex of the skull, and more
appropriate antibiotics based on sensitivities, as well as
local wound care, usually lead to successful outcomes.
■ In the scalp, all wounds, especially those allowed to heal
by secondary intention, will have some degree of
alopecia, which may necessitate a secondary revision,
with transfer of hair-bearing flaps.
■ When using a VAC device, either for temporary wound
management or for immobilization of skin grafts, the
avoidance of excessive pressure which can devitalize the
underlying periosteal bed is very important.
■ Tissue expansion of highly specialized hair-bearing scalp
has become an invaluable method for generating “like”
tissue for restoration of the hair, but great care should be
taken during the lengthy process of expansion to
minimize complications. In some patients, where the
tissues are particularly tight or if the tissues are expanded
too rapidly, wound dehiscence and expander exposure
can occur. If this is minor, local wound care and
antibiotics, together with slight deflation of the expander,
may allow the process to continue, albeit more slowly. If
H
I
J
K
L
M
N
O
Fig. 5.33, cont’d (H,I,J) The forehead was
repaired with a tailored scapular/parascapular flap
with an arterio- venous saphenous required to
bridge to the recipient vessels in the neck. (K, L,
M, N, O) This series of images shows the early
appearance of the bulky parascapular/scapula flap
as well as the final appearance after flap debulking
involving direct excision and liposuction.

122
SECTION II
CHAPTER 5 • Scalp and forehead reconstruction
principles of meticulous technique to minimize these
problems.
■ Other complications such as hematoma and seroma can
occur, but can be minimized with appropriate technique,
the use of drains, etc.
■ Free tissue transfers are lengthy procedures, often
undertaken in sick and elderly patients with other
co-morbidities, and thus they can have any of the general
complications that can arise with any prolonged
anesthetic and surgical procedure. To minimize
complications, the patient’s general health and nutrition
should be optimized preoperatively. Complication rates
are higher in head and neck free tissue transfers than for
elective breast free flap reconstruction.114 Nonetheless,
most centers report a very high success rate for head and
neck free flaps, in excess of 95%. Attention to detail at all
stages throughout the procedure and especially taking
great care with the vascular pedicle to avoid twisting and
distortion that can occur with movement of the head, and
to assure good flap perfusion before leaving the operating
room are key in ensuring a favorable outcome.
Postoperatively, careful flap monitoring, especially for the
elaborate methods such as by using the “crane” principle
espoused by Millard have all been used successfully. The
“crane” principle involves the temporary transfer of a
vascularized flap to a poorly vascularized site, and then
after a period of neovascularization, the flap is elevated
from the site but leaving behind the deepest part of the
flap (which is now vascularized and capable of
nourishing a skin graft) and transferred back to its
original site. This technique works well for wounds that
have not been heavily irradiated – these latter wounds
need permanent flap coverage.113
■ Common complications following local and regional flap
transfers include distal tip necrosis, which can be treated
conservatively if vital structures are not exposed.
Significant problems following use of local flaps are
usually due to errors in judgment and improper flap
selection and design. This is especially problematic if the
curvature of the scalp is not accounted for in the flap
design, as this will cause a tight skin closure, which
compromises the distal flap circulation leading to necrosis
and dehiscence. It is imperative that the surgeon has a
thorough understanding of flap anatomy and adheres to
A
B
Fig. 5.34  A patient with extensive burn scars of the forehead and right periorbital region, with skin grafts directly on bone. A pattern of the defect is made and transferred to
the back where a scapular/parascapular flap is designed and transferred to the upper face. Later, the right eyebrow was reconstructed with follicular hair grafts by Dr. Alfonso
Barrera, and a periocular osseointegrated implant by Dr. Elof Eriksson.
C
D
E

123
Secondary procedures
excision and repair. Small dog-ears often settle down
without revision. Other contour deformities due to bulky
flaps are also easily treated with liposuction or direct
debulking.
■ Depressions and indentations can be corrected with
dermis-fat grafting and structural fat grafting. The fat
grafting may need to be repeated to restore normal
contour.
■ Mobile structures such as the eyebrows and upper
eyelids can be easily displaced during forehead
reconstructions, producing obvious asymmetry. To
replace these to their normal location, local tissue
rearrangement with z-plasties, full-thickness skin
grafting, or the preliminary use of tissue expansion are
usually required.
■ If skin grafts have been used as part of the initial repair,
they will create a large area of alopecia in the scalp and
may be unsightly if used on the forehead, due to color
mismatch and contour deformity. In the scalp, secondary
staged tissue expansion is the commonest way of dealing
with the alopecia. In the forehead, attempts to improve
the color mismatch and contour abnormality have
included dermabrasion of the graft and overgrafting with
split-thickness grafts from the scalp. Alternatively, serial
excision or tissue expansion can be used.
■ Restoration of the hairline, which helps define the
subunits, is also a common goal of secondary
reconstruction. The temporal sideburn can be replaced
with a superiorly based transposition flap from the post
auricular region. In males, a VY advancement of lower
sideburn and beard area can be used to reconstruct the
first 24 h is mandatory, and any vascular compromise
should prompt an emergent return to the operating room
to correct the problem. In a large prospective study of
microvascular free-flap surgery outcomes by Khouri et al.
(in which the authors also participated), salvage rates
varied between 54 and 100% depending on the series.115
Secondary procedures
Secondary procedures in the scalp and forehead are very
often needed to achieve a satisfactory and aesthetic outcome.
They may be needed to address complications from wound
healing, repositioning of displaced natural landmarks, or as
planned second, third (or more) stages of a complex recon-
struction, with the goal of restoring to as close to “normal”
as possible.
■ Repair of widened scars that result from suture under
tension, which is common in scalp, and forehead
reconstruction may be requested. In the scalp, these scars
typically lack hair, and it can be difficult to completely
correct alopecia, as hair follicles are very susceptible to
tension, and although scar may be narrower, there may
still be some alopecia. The use of w-plasty and z-plasty
can help break up a long alopecic scar so that it becomes
less obvious (Fig. 5.30B). Care must be taken not to injure
the hair follicles. Microfollicular hair grafting has also
been used although scars are often not the most “fertile”
sites to ensure good hair graft take.116
■ Contour deformities, such as dog-ears at sites of pedicle
flap pivot points are fairly easily addressed with simple
A
B
Fig. 5.35  A patient who underwent a total face transplant to reconstruct a major post electrical facial burn,
showing the forehead and upper third of the face postoperative result.
C

124
SECTION II
CHAPTER 5 • Scalp and forehead reconstruction
lower aspect of the sideburn (Fig. 5.36).117 Sometimes a
combination of both the above methods may be used.
The anterior hairline can be repaired with a Juri type of
transposition flap, although the hair growth will be
abnormal.64–66 Alternatively, it can be restored as part of
scalp expansion to correct larger areas of alopecia with
serial tissue expansion.
■ Large subunit free tissue transfers may be required to
replace the entire forehead if it is unsightly, uneven, and
badly scarred from previous reconstructions. For a better
color match, flap prefabrication using expanded
neovascularized neck skin has been used by the
authors.118
■ In cases where the cranium has been resected, secondary
reconstructions and cranioplasty with bone grafts or
alloplastic or synthetic plates may be required. Stable and
well-perfused skin coverage over the bony defect is
essential for a successful outcome in these cases.
A
B
C
Fig. 5.36  A 25-year-old patient with unstable skin of the forehead and periorbital area due to irradiation for retinoblastoma in infancy. The unstable area was excised and
tailored a scapula flap used to resurface the area. Later reconstruction of temporal hairline and sideburn with scalp transposition flap and VY hair-bearing cheek flap, and
eyebrow reconstruction with follicular hair grafts.
D
E
Fig. 5.9 This series shows a 14-year-old girl who sustained a scalp avulsion
injury of the temporal scalp (A) due to hair entanglement in a fan (B). The
immediate result post replantation is shown (C), as well as a later result with
some, but incomplete hair growth (D).
Fig. 5.18 Seventy-year-old man with area of post irradiation necrosis of
posterior scalp with exposed bone (A). An axial musculocutaneous flap based
on the occipital artery is designed (B) and transposed to cover the defect (C).
The resulting donor site is skin grafted. The long-term result with good hair
growth is shown (D).
Fig. 5.25 (A) Fifty-three-year-old man with defect in hair-bearing temporal
region post excision of a chondroid syringoma, repaired with extended VY flap.
(B) Nineteen-year-old man with a granuloma of the temporal/forehead region,
repaired with a hair-bearing extended VY flap. Note the change of direction of
hair growth.
Fig. 5.26 Glabella–suprabrow defect: patient with glabella defect post excision
of sebaceous hyperplasia, repaired with bilateral VY advancement flaps, without
distortion of natural eyebrow landmarks.
Bonus images for this chapter can be found online at

125
Secondary procedures
1. Seitz IA, Gottlieb LJ. Reconstruction of scalp and forehead defects.
Clin Plast Surg. 2009;36:355–377. Techniques in scalp and forehead
reconstruction are detailed in this review.
2. TerKonda RP, Sykes JM. Concepts in scalp and forehead
reconstruction. Otolaryngol Clin North Am. 1997;30:519–539.
Anatomy and technical versatility are stressed in this primer on scalp
reconstruction. The roles of diverse methods in achieving optimal
coverage are discussed.
6. Jackson IT. Forehead Reconstruction. In: Local Flaps in Head and
Neck Reconstruction. 2nd ed. St Louis: Quality Medical Publishing;
2007. An extensive summary of local flap options especially for forehead
reconstruction by a master surgeon.
42. Temple CL, Ross DC. Scalp and forehead reconstruction. Clin Plast
Surg. 2005;32:377–390, vi–vii. The authors propose an algorithm for
scalp reconstruction. Surgical anatomy of the scalp is reviewed.
44. Angelos PC, Downs BW. Options for the management of forehead
and scalp defects. Facial Plast Surg Clin North Am. 2009;17:379–393.
This review covers methods in scalp wound management ranging from
allowing for secondary healing to performing free tissue transfer.
59. Leedy JE, Janis JE, Rohrich RJ. Reconstruction of acquired scalp
defects: an algorithmic approach. Plast Reconstr Surg. 2005;116:54e–
72e. A multifaceted algorithm for scalp reconstruction is presented. The
reconstructive surgeon is urged to achieve not only wound closure, but
also an aesthetically optimal result.
73. Pribaz JJ, Chester C, Barrall DT. The extended VY flap. Plast
Reconstr Surg. 1992;90:275–280. Details on VY, extended and double
extended VY flaps that are very useful in forehead reconstruction.
106. Pribaz JJ, Caterson EJ. The evolution and limitations of
conventional autologous reconstruction of the head and neck: one
perspective and a comparison of conventional reconstruction with
face transplantation. J Craniofac Surg. 2013;24(1):99–107. A summary
of the advances and inadequacies in conventional reconstruction and the
implications of the dawn of a new era of allotransplantation.
117. Ridgway E, Pribaz JJ. The reconstruction of male hair-bearing
facial regions. Plast Reconstr Surg. 2011;127(1):131–141. A good
summary of options for restoration of the hairline which is important in
scalp and forehead reconstruction.
Access the complete reference list online at

125.e1
References
References
1. Seitz IA, Gottlieb LJ. Reconstruction of scalp and forehead defects.
Clin Plast Surg. 2009;36:355–377. Techniques in scalp and forehead
reconstruction are detailed in this review.
2. TerKonda RP, Sykes JM. Concepts in scalp and forehead
reconstruction. Otolaryngol Clin North Am. 1997;30:519–539.
Anatomy and technical versatility are stressed in this primer on scalp
reconstruction. The roles of diverse methods in achieving optimal
coverage are discussed.
3. Tolhurst DE, Carstens MH, Greco RS, et al. The surgical anatomy
of the scalp. Plast Reconstr Surg. 1991;87:603–612.
4. Mitz V, Peyronie M. The superficial musculo-aponeurotic system
(SMAS) in the parotid and cheek area. Plast Reconstr Surg.
1976;58:80–88.
5. Gonzalez-Ulloa M. Regional aesthetic units of the face. Plast
Reconstr Surg. 1987;79:489–490.
6. Jackson IT. Forehead Reconstruction. In: Local Flaps in Head and
Neck Reconstruction. 2nd ed. St Louis: Quality Medical Publishing;
2007. An extensive summary of local flap options especially for forehead
reconstruction by a master surgeon.
7. Sood R, Coleman JJ III. Scalp and calvarial reconstruction. In:
Achauer BM, Eriksson E, Guyuron B, et al., eds. Plastic Surgery
Indications, Operations and Outcomes, Vol. 3: Head and Neck Surgery.
St. Louis: Mosby; 2000.
8. Swelstad MR, Bentz M. Scalp, calvarial and forehead
reconstruction. In: Serletti JM, Taub PJ, Wu LC, Stutsky DJ, eds.
Current Reconstructive Surgery. New York: McGraw-Hill Education;
2012:369–378.
9. Gor DM, Langer JE, Loevner LA. Imaging of cervical lymph nodes
in head and neck cancer: the basics. Radiol Clin North Am.
2006;44:101–110, viii.
10. Stuzin JM, Wagstrom L, Kawamoto HR, et al. Anatomy of the
frontal branch of the facial nerve. Plast Reconstr Surg. 1989;83:265.
11. Knize DM. A study of the supraorbital nerve. Plast Reconstr Surg.
1995;96:564–569.
12. Argenta LC, Dingman RO. Total reconstruction of aplasia cutis
congenital involving the scalp, skull and dura. Plast Reconstr Surg.
1986;77:650.
13. Ribuffo D, Costantini M, Gullo P, Houseman ND, Taylor GI.
Aplasia cutis congenita of the scalp, the skull, and the dura. Scand
J Plast Reconstr Surg Hand Surg. 2003;37(3):176–180.
14. Schnabl SM, Horch RE, Ganslandt O, et al. Aplasia cutis congenital
– plastic reconstruction of three scalp and skull defects with two
opposed scalp rotation flaps and split-thickness skin grafting.
Neuropediatrics. 2009;40(3):134–136.
15. Kohout MP, Hansen M, Pribaz JJ, Mulliken JB. Arterovenous
malformations of the head and neck. Plast Reconstr Surg.
1998;102:634–654.
16. McGrath M. Scalping: the savage and the surgeon. Clin Plast Surg.
1983;10:569–688.
17. Miller GD, Anstee EJ, Snell JA. Successful replantation of an
avulsed scalp by microvascular anastomoses. Plast Reconstr Surg.
1976;58:133–136.
18. Cheng K, Zhou S, Jiang K, et al. Microsurgical replantation of the
avulsed scalp: report of 20 cases. Plast Reconstr Surg. 1996;97:1099.
19. Achauer BM. Scalp reconstruction. In: Achauer BM, ed. Burn
Reconstruction. New York: Thieme Medical Publishers; 1991:13.
20. Spies M, McCauley RL, Mudge BP, et al. Management of acute
calvarial burns in children. J Trauma. 2003;54:765–769.
21. Labow BI, Rosen H, Pap SA, et al. Microsurgical reconstruction: a
more conservative method of managing large scalp defects? J
Reconstr Microsurg. 2009;25:465–474.
22. Luce EA, Hoopes JE. Electrical burn of the scalp and skull. Case
report. Plast Reconstr Surg. 1974;54:359–363.
23. Headington JT. Cicatricial alopecia. Dermatol Clin. 1996;14:773–
782.
24. Czajkowski R, Placek W, Drewa G, et al. FAMMM syndrome:
pathogenesis and management. Dermatol Surg. 2004;30:291–296.
25. Fusaro RM, Lynch HT. The FAMMM syndrome: epidemiology and
surveillance strategies. Cancer Invest. 2000;18:670–680.
26. Arneja JS, Gosain AK. Giant congenital melanocytic nevi. Plast
Reconstr Surg. 2007;120:26e–40e.
27. Marghoob AA, Borrego JP, Halpern AC. Congenital melanocytic
nevi: treatment modalities and management options. Semin Cutan
Med Surg. 2007;26:231–240.
28. Eisen DB. Sebaceous lesions and their associated syndromes: part
I. J Am Acad Dermatol. 2009;61:549–560.
29. Ball EA, Hussain M, Moss AL. Squamous cell carcinoma and basal
cell carcinoma arising in a naevus sebaceous of Jadassohn: case
report and literature review. Clin Exp Dermatol. 2005;30:259–260.
30. Fattah A, Pollock J, Maheshwar A, et al. Big bad BCCs: craniofacial
resection and reconstruction for atypical basal cell carcinomata. J
Plast Reconstr Aesthet Surg. 2010;63:e433–e441.
31. Naumann IC, Cordes SR. Giant basal cell carcinoma of the
forehead with extensive intracranial involvement. Ann Otol Rhinol
Laryngol. 2007;116:663–666.
32. Cassarino DS, Derienzo DP, Barr RJ. Cutaneous squamous cell
carcinoma: a comprehensive clinicopathologic classification. Part
one. J Cutan Pathol. 2006;33:191–206.
33. O’Brien CJ, McNeil EB, McMahon JD, et al. Significance of clinical
stage, extent of surgery, and pathologic findings in metastatic
cutaneous squamous carcinoma of the parotid gland. Head Neck.
2002;24:417–422.
34. Garbe C, Eigentler TK. Diagnosis and treatment of cutaneous
melanoma: state of the art 2006. Melanoma Res. 2007;17:117–127.
35. Lang PG. Current concepts in the management of patients with
melanoma. Am J Clin Dermatol. 2002;3:401–426.
36. Larralde M, Gomar B, Boggio P, et al. Neonatal kerion Celsi: report
of three cases. Pediatr Dermatol. 2010;27:361–363.
37. Ilkit M. Favus of the scalp: an overview and update.
Mycopathologia. 2010;170:143–154.
38. Holland KE, Steffes B, Nocton JJ, et al. Linear scleroderma en coup
de sabre with associated neurologic abnormalities. Pediatrics.
2006;117:e132–e136.
39. Yu-Feng L, Lai G, Zhi-Yong Z. Combined treatments of facial
contour deformities resulting from Parry-Romberg syndrome. J
Reconstr Microsurg. 2008;24:333–342.
40. Carlson GW, Murray DR, Lyles RH, et al. Sentinel lymph node
biopsy in the management of cutaneous head and neck melanoma.
Plast Reconstr Surg. 2005;115:721–728.
41. Eicher SA, Clayman GL, Myers JN, et al. A prospective study of
intraoperative lymphatic mapping for head and neck cutaneous
melanoma. Arch Otolaryngol Head Neck Surg. 2002;128:241–
246.
42. Temple CL, Ross DC. Scalp and forehead reconstruction. Clin Plast
Surg. 2005;32:377–390, vi–vii. The authors propose an algorithm for
scalp reconstruction. Surgical anatomy of the scalp is reviewed.
43. Millard R. Principalization of Plastic Surgery. Boston: Little, Brown;
1986.
44. Angelos PC, Downs BW. Options for the management of forehead
and scalp defects. Facial Plast Surg Clin North Am. 2009;17:379–393.
This review covers methods in scalp wound management ranging from
allowing for secondary healing to performing free tissue transfer.
45. Venturi ML, Attinger CE, Mesbahi AN, et al. Mechanisms and
clinical applications of the vacuum-assisted closure (VAC) device:
a review. Am J Clin Dermatol. 2005;6:185–194.
46. Marathe US, Sniezek JC. Use of the vacuum-assisted closure
device in enhancing closure of a massive skull defect. Laryngoscope.
2004;114:961–964.
47. Molnar JA, DeFranzo AJ, Marks MW. Single-stage approach to
skin grafting the exposed skull. Plast Reconstr Surg.
2000;105:174–177.
48. Raposio E, Nordstrom RE, Santi PL. Undermining of the scalp:
quantitative effects. Plast Reconstr Surg. 1998;101:1218–1222.
49. Raposio E, Santi PL, Nordstrom RE. Serial scalp reduction: a
biomechanical approach. Dermatol Surg. 1999;25(3):210–214.
50. Unger MG. Scalp reduction. Clin Dermatol. 1992;10:345–355.

125.e2
SECTION II
CHAPTER 5 • Scalp and forehead reconstruction
51. Argenta LC, Watanabe MJ, Grabb WC. The use of tissue expansion
in head and neck reconstruction. Ann Plast Surg. 1982;11:31.
52. Manders EK, Schendler MJ, Furrey JA, et al. Skin expansion to
eliminate large scalp defects. Plast Reconstr Surg. 1984;74:493–507.
53. Antonyshyn O, Gruss JS, Zuker R, et al. Tissue expanders in head
and neck reconstruction. Plast Reconstr Surg. 1988;82(1):58–68.
54. Gürlek A, Alaybeyoğlu N, Demir CY, et al. Aesthetic
reconstruction of large scalp defects by sequential tissue expansion
without interval. Aesthetic Plast Surg. 2004;28:245–250.
55. Joss GS, Zoltie N, Chapman P. Tissue expansion technique and the
transposition flap. Br J Plast Surg. 1990;43:328–333.
56. Austad ED. Complications in tissue expansion. Clin Plast Surg.
1987;14:549–550.
57. Antonyshyn O, Gruss JS, Mackinnon SE, et al. Complications of
soft tissue expansion. Br J Plast Surg. 1988;41:239–250.
58. Furlanetti LL, de Oliveira RS, Santos MV, et al. Multiple cranial
burr holes as an alternative treatment for total scalp avulsion.
Childs Nerv Syst. 2010;26:745–749.
59. Leedy JE, Janis JE, Rohrich RJ. Reconstruction of acquired scalp
defects: an algorithmic approach. Plast Reconstr Surg. 2005;116:54e–
72e. A multifaceted algorithm for scalp reconstruction is presented. The
reconstructive surgeon is urged to achieve not only wound closure, but
also an aesthetically optimal result.
60. Orticochea M. Four flap scalp reconstruction technique. Br J Plast
Surg. 1967;20:159–171.
61. Orticochea M. New three-flap reconstruction technique. Br J Plast
Surg. 1971;24:184–188.
62. Arnold PG, Rangarathnam CS. Multiple flap scalp reconstruction:
Orticochia revisited. Plast Reconstr Surg. 1982;69:605–613.
63. Lesavoy MA, Dubrow TJ, Schwartz RJ, et al. Management of large
scalp defects with local pedicle flaps. Plast Reconstr Surg.
1993;91:783–790.
64. Juri J. Use of parieto-occipital flaps in the surgical treatment of
baldness. Plast Reconstr Surg. 1975;55:456–460.
65. Juri J, Juri C. Aesthetic aspects of reconstructive scalp surgery. Clin
Plast Surg. 1981;8:243.
66. Juri J. TPO and TPOP scalp flaps. In: Strauch B, Vasconez L,
Hall-Findlay E, eds. Grabb’s Encyclopedia of Flaps. 2nd ed.
Philadelphia: Lippincott-Raven; 1998.
67. Hussain W, Mortimer NJ, Salmon PJ, et al. Galeal/periosteal flaps
for the reconstruction of large scalp defects with exposed outer
table. Br J Dermatol. 2010;162:684–686.
68. Kim JY, Buck DW II, Johnson SA, et al. The temporoparietal fascial
flap is an alternative to free flaps for orbitomaxillary
reconstruction. Plast Reconstr Surg. 2010;126:880–888.
69. Carstens MH, Greco RJ, Hurwitz DJ, et al. Clinical applications of
the subgaleal fascia. Plast Reconstr Surg. 1991;87:615–626.
70. Mathes ST, Nahai F. Trapezius flap. In: Mathes ST, Nahai F, eds.
Reconstructive Surgery – Principles, Anatomy, Technique. New York:
Churchill-Livingston; 1997.
71. Haas F, Weiglein A, Schwarzl F, et al. The lower trapezius
musculocutaneous flap from pedicled to free flap: anatomical basis
and clinical applications based on the dorsal scapular artery. Plast
Reconstr Surg. 2004;113:1580–1590.
72. Liu R, Gullane P, Brown D, et al. Pectoralis major myocutaneous
pedicled flap in head and neck reconstruction: retrospective
review of indications and results in 244 consecutive cases at the
Toronto General Hospital. J Otolaryngol. 2001;30:34–40.
73. Pribaz JJ, Chester C, Barrall DT. The extended VY flap. Plast
Reconstr Surg. 1992;90:275–280. Details on VY, extended and double
extended VY flaps that are very useful in forehead reconstruction.
74. McLean DH, Buncke HJ. Autotransplant of omentum to a large
scalp defect with microsurgical revascularization. Plast Reconstr
Surg. 1972;49:268–274.
75. Ikuta Y. Autotransplant of omentum to cover large denudation of
the scalp. Plast Reconstr Surg. 1975;55(4):490–493.
76. Losken A, Carlson GW, Culbertson JH, et al. Omental free flap
reconstruction in complex head and neck deformities. Head Neck.
2002;24:326–331.
77. Ohmori K. Free scalp flap surgery. Ann Plast Surg. 1980;5:17–23.
78. Mullholland S, Boyd JB, McCabe S, et al. Recipient vessels in head
and neck microsurgery: radiation effect and vessel access. Plast
Reconstr Surg. 1993;92(4):628–632.
79. Takamatsu A, Harashina T, Inoue T. Selection of appropriate
recipient vessels in difficult microvascular head and neck
reconstruction. J Reconstr Microsurg. 1996;12(8):499–513.
80. Yazar S. Selection of recipient vessels in microsurgical free tissue
reconstruction of head and neck defects. Microsurgery.
2007;27:588–594.
81. Miller MJ, Schusterman MA, Reed GP, et al. Interposition vein
grafts in head and neck reconstructive microsurgery. J Reconstr
Microsurg. 1993;9(3):245–251.
82. Ethunandan M, Cole R, Flood TR. Corlett loop for microvascular
reconstruction in a neck depleted of vessels. Br J Oral Maxillofac
Surg. 2007;45:493–495.
83. Chalian AA, Anderson TD, Weinstein GS, et al. Internal jugular
vein versus external jugular vein anastomosis: implications for
successful free flap transfer. Head Neck. 2001;23(6):475–478.
84. Amin AAW, Baldwin BJ, Miller MJ, et al. Secondary free flap in
head and neck reconstruction. J Reconstr Microsurg.
1998;14(6):365–369.
85. Nakayama B, Kamei Y, Toriyama K, et al. Usefulness of a first
transferred free flap vascular pedicle for secondary microvascular
reconstruction in the head and neck. Plast Reconstr Surg.
2002;109(4):1246–1253.
86. Wells MD, Luce EA, Edwards AL, et al. Sequentially linked free
flaps in head and neck reconstruction. Clin Plast Surg.
1994;21:59–67.
87. Horng SY, Chen MT. Reversed cephalic vein: a lifeboat in head
and neck free flap reconstruction. Plast Reconstr Surg.
1993;92(4):752–753.
88. Neligan PC, Mullholland S, Irish J, et al. Flap selection in cranial
base reconstruction. Plast Reconstr Surg. 1996;98:1159–1166.
89. McCombe D, Donato R, Hofer S, et al. Free flaps in treatment of
locally advanced malignancy of the scalp and forehead. Ann Plast
Surg. 2002;48:600–606.
90. Pennington DG, Stern HS, Lee KK. Free flap reconstruction of
large defects of the scalp and calvarium. Plast Reconstr Surg.
1989;83:655–661.
91. Furnas H, Lineweaver WC, Alpert BS, et al. Scalp reconstruction
by microvascular free flap transfer. Ann Plast Surg. 1990;24(5):431.
92. Lutz BS, Wei FC, Chen HC, et al. Reconstruction of scalp defects
with free flaps in 30 cases. Br J Plast Surg. 1998;51:186–190.
93. van Driel AA, Mureau MA, Goldstein DP, et al. Aesthetic and
oncologic outcome after microsurgical reconstruction of complex
scalp and forehead defects after malignant tumor resection: an
algorithm for treatment. Plast Reconstr Surg. 2010;126:460–470.
94. Gordon L, Buncke HJ, Alpert BS. Free latissimus dorsi muscle flap
with split-thickness skin graft cover: a report of 16 cases. Plast
Reconstr Surg. 1998;70(2):173–178.
95. Lipa JE, Butler CE. Enhancing the outcome of free latissimus dorsi
muscle flap reconstruction for scalp defects. Head Neck.
2004;26:46–52.
96. Borah GC, Hidalgo DA, Wey PD. Reconstruction of extensive scalp
defects with rectus free flaps. Ann Plast Surg. 1995;34:281–285.
97. Cicarelli ZN, Ariyan S, Cuomo CB. Single stage repairs of complex
scalp and cranial defects with free radial forearm flap. Plast
Reconstr Surg. 1986;77:577–585.
98. Santamaria E, Granados M, Barrera-Franco JL. Radial forearm free
tissue transfer for head and neck reconstruction: versatility and
reliability of a single donor site. Microsurgery. 2000;20:195–200.
99. Chiu DTW, Sherman JE, Edgerton BW. Coverage of calvarium
with large parascapular flap. Ann Plast Surg. 1989;42:60.
100. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap
concept based on the septocutaneous artery. Br J Plast Surg.
1984;37:149–159.
101. Pribaz JJ, Orgill DP, Epstein MD, Sampson CE, Hergrueter CA.
Anterolateral thigh free flap. Ann Plast Surg. 1995;34:585–592.

125.e3
References
102. Ozkan O, Coskunfirat OK, Ozgentas HE, et al. Rationale for
reconstruction of large scalp defects using the anterolateral thigh
flap: structural and aesthetic outcomes. J Reconstr Microsurg.
2005;21:539–545.
103. Amin A, Rifaat M, Civantos F, et al. Free anterolateral thigh flap
for reconstruction of major craniofacial defects. J Reconstr
Microsurg. 2006;22:97–104.
104. Lutz BS. Aesthetic and functional advantages of the anterolateral
flap in reconstruction of tumor-related scalp defects. Microsurgery.
2002;22:258–264.
105. Weinzweig N, Davies B, Polley JW. Microsurgical forehead
reconstruction: an aesthetic approach. Plast Reconstr Surg.
1995;95:647–651.
106. Pribaz JJ, Caterson EJ. The evolution and limitations of
conventional autologous reconstruction of the head and neck: one
perspective and a comparison of conventional reconstruction with
face transplantation. J Craniofac Surg. 2013;24(1):99–107. A summary
of the advances and inadequacies in conventional reconstruction and the
implications of the dawn of a new era of allotransplantation.
107. Hui-Chou HG, Nam AJ, Rodriguez ED. Clinical facial composite
tissue allotransplantation: a review of the first four global
experiences and future implications. Plast Reconstr Surg.
2010;125:538–546.
108. Pomahac B, Lengele B, Ridgway EB, et al. Vascular considerations
in composite midface allotransplantation. Plast Reconstr Surg.
2010;125(2):517–524.
109. Pomahac B, Pribaz JJ, Eriksson E, et al. Three patients with full
facial transplantation. N Engl J Med. 2012;366:715–722.
110. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the
body: experimental study and clinical application. Br J Plast Surg.
1987;40:113.
111. Wooden WA, Curtsinger LJ, Jones NF. The four-poster halo vest
for protection of a microvascular free-tissue transfer reconstruction
of the scalp. Plast Reconstr Surg. 1995;95(1):166–167.
112. Smit JM, Zeebregts CJ, Acosta R, et al. Advancements in free flap
monitoring in the last decade: a critical review. Plast Reconstr Surg.
2010;125:177–185.
113. Millard DR. The crane principle for the transport of subcutaneous
tissue. Plast Reconstr Surg. 1969;43:451–462.
114. Singh B, Cordeiro PG, Santamaria E, et al. Factors associated with
complications in microvascular reconstruction of head and neck
defects. Plast Reconstr Surg. 1999;103:403–411.
115. Khouri RK, Cooley BC, Kunselman AR, et al. A prospective study
of microvascular free-flap surgery and outcome. Plast Reconstr
Surg. 1998;102:711–721.
116. SRousso DE, Presti PM. Follicular unit transplantation. Facial Plast
Surg. 2008;24:381–388.
117. Ridgway E, Pribaz JJ. The reconstruction of male hair-bearing
facial regions. Plast Reconstr Surg. 2011;127(1):131–141. A good
summary of options for restoration of the hairline which is important in
scalp and forehead reconstruction.
118. Mathy J, Pribaz JJ. Prelamination and prefabrication in current
aesthetic facial reconstruction. Clin Plast Surg. 2009;36:493–505.

SECTION II • Head and Neck Reconstruction
6 
Aesthetic nasal reconstruction
Frederick J. Menick
SYNOPSIS
■ The field of plastic surgery originated with the first early attempts to
reconstruct the face, especially the nose.
■ The face tells the world who we are and materially influences what we
can become.
■ The restoration of a normal appearance and an open airway to allow
comfortable breathing remains the goal.
■ Treatment choices will depend on an understanding of the deformity
and wound healing, missing anatomic layers, available donor tissues,
surgical planning, the surgeon’s ability to modify them into “like”
tissue, and the advantages, disadvantages, and limitations of the
technique, and its ability to achieve the desired outcome.
Introduction
The primary functions of the nose are to look normal and
allow easy nasal breathing.
The success of reconstruction will depend upon the site,
size, and depth of the defect, donor availability and, most
importantly, the surgeon’s choices in material, method, and
approach. An understanding of the deformity, both anatomi-
cally and aesthetically, and of wound healing and tissue
transfer are required. The advantages, disadvantages, and
limitations of each material, technique, and stage must be
understood. What is missing must be replaced – external skin
which matches adjacent facial skin in color and texture, a
midlayer support of soft tissue, bone and cartilage, and inter-
nal lining. Covering skin must be thin, conforming, and vas-
cular. Lining must be thin, supple, and vascular, neither
occluding the airway nor distorting external nasal shape due
to excessive bulk or stiffness. A rigid midlayer must support,
shape, and brace the soft tissues against gravity, tension, and
scar contraction to prevent collapse and create contour. The
surgeon must replace tissues similar in kind to those which
are missing. However, although donor tissues may have some
characteristics which are similar, all tissues must be modified
– thinned and shaped – to become “like” tissue. Flat forehead
skin, ear or rib cartilage, and traditional lining replacements
have little similarity to the “normal” nose.
Access the Historical Perspective section online at

Basic science/disease process and
surgical timing
Nasal deformity may follow congenital malformation, trauma
(including burns), and the sequela of skin cancer treatment by
excision or radiation, infection, or immune disease.25
Often reconstruction is delayed for weeks to years to allow
wound stabilization, wound maturation, and verification of
disease control.
The extent of the tumor can be estimated visually and an
additional margin of normal tissue is excised, based on clini-
cal judgment or published “rules of thumb”. Margins can be
evaluated by permanent histologic section or intraoperative frozen
sections to verify the completeness of excision, prior to wound
closure. However, large tissue excisions with multiple margins
are burdensome for the hospital pathologist, are time-
consuming, and disrupt the operative schedule.
To better evaluate peripheral and deep margins, the Margin
Check Technique can be applied. An en bloc excision is per-
formed, based on physical examination, histology, and clinical
judgment. Then, additional 1–2 mm slivers of the entire lateral
and deep margins are excised, oriented for the hospital
pathologist, and the wound dressed. A delayed primary
repair is scheduled 24–72 h later, pending verification of
complete tumor excision.
Moh’s Histographic Surgery, normally performed in an out-
patient setting, utilizes a unique serial horizontal section and
mapping technique to maximize cure rate. It is especially
useful for difficult tumors – skin cancers greater than 2 cm in
Access video content for this chapter online at expertconsult.com

126.e1
Historical perspective
Historical perspective
The history of facial and nasal reconstruction is the history of
plastic surgery.1
Cover
Early surgeons focused on the replacement of external skin.
Although cartilage, bone, and mucous membrane are missing
in larger defects, skin is the most obvious deficiency.
The origins of forehead rhinoplasty (the Indian method)
are obscure.2 Nasal repair was described in the Hindu Book of
Revelation, the Samhita Susruta, as early as 400 AD and prob-
ably was performed before the birth of Christ. Italian surgeons,
Branca and Tagliocozzi, reconstructed the nose with skin from
the upper arm in the late 1400s.3,4
The first written English account of an Indian midline
forehead rhinoplasty appeared in the Madras Gazette in 1793
and was republished in the Gentleman’s Magazine of London
one year later. Carpue,5 an English surgeon, published his
account of two successful operations in 1816. This classic,
vertically oriented median forehead flap design was popular-
ized in the United States by Kazanjian6 in 1946. The base of
the flap, which harvested midline forehead tissues and twisted
180°, was supplied by paired supratrochlear vessels. Its
pedicle base was located above the eyebrows.
Early repairs were unlined. So the external shape of the
nose and its airways became distorted by the contracting scar
on the underlying raw surface of the external skin flap.7
The importance of lining replacement did not become clear
until the period between 1840 and World War I.8 Residual
intranasal mucosa mucous seemed inadequate. Petralli folded
the distal end of the flap onto itself for lining around 1842.
However, because of the high pivot point of the classic median
flap above the brows, its length was inadequate to create a
long columella, satisfactory projection, or to permit infolding
for lining without transferring hair-bearing skin on the distal
end of the flap.
To increase flap length distally, Auvert, in 1850, slanted the
flap’s design obliquely across the forehead. German surgeons
designed forehead flaps horizontally, supplied by the supra-
orbital vessels on one side. In 1935, Gillies8 described an up-
and-down flap which was centered over one supraorbital
pedicle, passed into the hair-bearing scalp, and then descended
back into the forehead. In 1942, Converse9,10 modified the
up-and-down flap by creating a long pedicle based on the
lateral blood supply of the scalp to camouflage scars within
the hair-bearing skin. Other designs included New’s sickle
flap,11 which transferred skin from the temple recess based on
the ipsilateral superficial temporal vessels, or Washio’s flap,12
which transferred skin from behind the ear, based on the
anastomosis of the postauricular and superficial temporal
vessels.
The converse scalping flap, lined by folding its distal end
onto itself or by prelamination, became the most commonly
used method during the late twentieth century.
Unfortunately, these modifications created a forehead
defect that was harder to close.
To avoid the limitations created by the high pivot point of
the median forehead flap, other surgeons lengthened its
design by modifying incisions at the pedicle’s base. Lisfranc,
in 1829, extended one incision lower than the other at the base
of the pedicle. Dieffenbach lengthened one incision until it
reached the defect. Labat curved his incisions proximally,
centering the flap over the medial brow and canthus on one
side, creating a unilaterally based vertical flap.
These innovations reduced the twist of the pedicle base and
brought the flap closer to the recipient site by lowering its
point of rotation. This vertical paramedian flap, transferred
forehead tissue on a unilateral pedicle blood supply, located
near the medial canthus. The anatomic studies of McCarthy13
and Reece14 demonstrate that the forehead is perfused by an
arcade of vessels supplied by the supraorbital, supratrochlear,
infraorbital, dorsal nasal, and angular branches of facial artery
and on branches of the superficial temporal artery. A rich
plexus of vessels, centered on the medial canthus, reliably
perfuse a unilateral flap.
Refinements developed to minimize donor deformity.
Velpech, in 1828, designed his flap as a reversed Ace of Spades,
with its stem forming the columella and its tapering tip as the
pedicle. Labat, in 1834, designed a similar tripod shaped flap,
with limbs extending obliquely across the forehead. Millard,15
in the 1960s, used a seagull-shaped flap with a central vertical
component, which covers the dorsum, tip and columella, and
horizontal lateral wings, which extended horizontally resur-
facing the ala. Undermining of adjacent wound edges allowed
partial closure and a relatively inconspicuous midline
T-shaped scar, even in large defects.
Today, the vertical paramedian forehead flap, with a uni-
lateral supratrochlear pedicle, is the first choice for nasal
repair because of its vascularity, size, reach, reliability, and
relatively minimal morbidity. Importantly, because a unilat-
eral vertical flap does not encroach on the opposite forehead,
a second vertical flap can be harvested with relative ease.
In modern times, forehead expansion has been used to
increase the available surface area of the forehead, ease
closure, and minimize donor deformity when forehead
dimension is limited in height or width due to a low hairline
or prior forehead scarring.
Lining
As Harold Gillies stated in 1920, “One is struck chiefly with
the lack of appreciation of the need for lining membrane for
all mucus lined cavities. In actual fact, except that the forehead
skin most closely resembles nose skin, the origin of cover is
the least important”.16,17
For at least 2000 years, surgeons placed a flap over a full-
thickness defect but left its raw undersurface to heal second-
arily. Unfortunately, the external shape of the nose and the
airways became distorted by contracting scar. In the mid-
eighteenth century, Petralli folded the distal end of the flap on
itself to form, in a manner of speaking, a tip, ala, and colu-
mella. Volkman, in 1873, turned down tissue lying adjacent to
the defect as hingeover flaps. Thiersch transferred flaps from
other facial areas in 1879.7 Millard,15 in the twentieth century,
rolled over bilateral nasolabial flaps to line both the alae and
columella.
In 1898, Loosen applied a skin graft to the underlying raw
surface of the covering flap during flap transfer. However, the
“take” was inconsistent and late contracture was common.
Others placed a split- or full-thickness skin graft on the deep
surface of the forehead flap during a preliminary operation.

126.e2
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
Weeks later, once the viability of the graft was assured, the
skin grafted flap was transferred to supply both cover and
lining. Gillies,18 in 1943, popularized prelaminating the fore-
head flap with composite chondrocutaneous grafts. In 1956,
Converse19,20 recommended septal mucoperichondrial carti-
lage grafts. However, these methods of prelamination (for-
merly referred to as prefabrication), delayed formal repair and
created a relatively unsupported and shapeless nose.
Gillies21 developed the Skin Graft Inlay Method for the
saddle nose deformity of syphilis and leprosy. If lining and
support were lost but the overlying nasal skin remained
intact, he released scar on the undersurface of the external
skin and applied a skin graft to the underlying raw surface.
A permanent internal prosthesis was worn to splint the graft
and maintain nasal shape and airway patency.
Burget,22 realizing that the forehead is composed of skin,
subcutaneous fat, and underlying frontalis muscle, tunneled
a cartilage graft within a vascularized pocket within the
subcutaneous fat of a full-thickness forehead flap. The deep
undersurface of the frontalis muscle was skin grafted for
lining. The buried cartilage graft “stented” the skin graft
lining, much like Gillies’ external splint.
Burget and Menick23 popularized the use of residual intra-
nasal lining flaps, based on axial vessels, for lateral, heminasal,
and near-total nasal defects. Because such intranasal lining
flaps were thin and relatively reliable, primary cartilage grafts
could be employed simultaneously to build a delicate hard
tissue layer to support and shape the nose during the initial
stages of reconstruction.
Menick24,25 modified the traditional folded flap and lining
skin graft approaches. Because the distal end of a folded
forehead flap or a lining skin graft heal to the adjacent residual
nasal lining within 3–4 weeks, the new reconstructed lining is
not dependent on the flap’s pedicle for survival. The distal
end of a folded flap (cut free from the proximal flap) or a skin
graft (which was initially revascularized from the forehead
flap’s deep surface) survive, even when the covering flap is
completely re-elevated. This permits the placement of a
delayed primary support framework over the newly vascular-
ized lining, prior to pedicle division.
Over the last decade, distant tissue has been transferred for
lining, as a free flap. Until recently, the technical elegance of
microsurgery has not matched the artistry required to make
a normal nose. However, recent advancements by Burget and
Walton,26 employing multiple individual forearm skin paddles
and a two-stage forehead flap with an intermediate to debulk
the midvault and Menick and Salibian’s folded single paddle
radial forearm flap, combined with a three-stage forehead
flap, have produced good results.
Support
Historically, lining necrosis, infection, or excessive bulk pre-
cluded the early placement of cartilage grafts. Prelaminated
composite chondrocutaneous grafts for the nostril margins or
large cantilever bone grafts, fixed to the nasal bones, provided
incomplete support initially. Without primary support place-
ment, unchecked forces of healing led to contracted scars, pin
cushioning, and airway collapse. Additional support grafts
were sometimes placed secondarily but the results were
limited due to the difficulty of molding soft tissues after col-
lapse and scar contraction.
Realizing that a complete cartilage and bone framework
must be placed early to support, shape, and brace the repair,
Burget and Menick22,23 combined primary cartilages grafts
with thin, vascular intranasal flaps. Menick25 recommended a
three-stage full-thickness forehead flap approach, combining
primary and delayed primary cartilage grafts and staged soft
tissue debulking during an intermediate operation, prior to
pedicle division.

127
Planning an aesthetic nasal reconstruction
dimension of a skin graft or flap were determined by the
apparent, but often distorted, defect. The emphasis was on
tissue transfer (skin graft or flap), blood supply, or the replace-
ment of anatomic layers (cover, lining, support). Scars and
additional donor injury were overriding concerns. A compre-
hensive plan to restore multiple, exact, independent, 3D facial
features was rarely envisioned.
This traditional approach failed to appreciate the strong
motivation of patients to look as they did before. It followed
a “less is more”, cautious approach, employing principles
with little expectation of restoring the normal.
False principles
Design the flap from a pattern of the defect
Traditionally, skin grafts or flaps are designed to replace the
existing defect. But the defect does not reflect what is missing
and what needs to be replaced. Fresh wounds are enlarged
by edema, local anesthesia, tissue tension, and gravity. Old
wounds may be contracted by secondary intention healing or
distorted by prior injury or repair.
To restore the normal, the “true” tissue loss must be identi-
fied the “true” defect replaced after returning “the normal to
its normal position”. Then the defect is filled with exactly
measured replacements.
Take extra tissue to be safe
Transferring extra tissue for “good measure” or out of fear
for vascularity only complicates the reconstruction. If too
much tissue is transferred, adjacent landmarks are displaced
outward. Additional stages will be needed to excise the extra
bulk and restore unit outline.
Make the flap smaller to preserve the donor site
Sharing tissue from an area of excess to one of deficiency is a
basic surgical tool but the temptation to cheat the recipient
site to preserve the donor site must be avoided.
Central features, such as the nose or lip, have an exact
border outline and position. Missing tissues must be replaced
in exact quantity to avoid distortion of the size, shape, and
position of the nasal subunit by dragging the borders of the
defect inward with tissue replacement which is too small.
Employ a tissue expander to conserve the forehead
donor site
The nose is an unforgiving facial feature, while the forehead
is a forgiving one. Although useful if the hairline is exception-
ally low or the forehead is scarred or previously harvested,
the routine use of skin expansion is unnecessary. The nose
comes first. The forehead donor is of secondary importance.
Use an expander only if it will contribute to the overall nasal
repair.
Never throw anything away
Surgeons are taught to preserve tissue. However, if skin is
transferred to resurface only part of a facial feature, it may
appear as a distracting patch, outlined by scars. It is often
helpful to alter the defect and discard extra skin prior to
repair, even if this makes the defect larger. Discardable tissues
may be used for other purposes – hingeover lining, subcuta-
neous bulk, or shifted to resurface an adjacent injury.
size, recurrent, those with poorly defined visible borders,
morphea or sclerotic basal cell cancers, and those in difficult
locations, such as nose, ear, or eye, where maximum tissue
preservation is desirable.
Staged excision with delayed repair is especially advanta-
geous in the more extensive cancer which requires more
complex reconstruction. Ideally, the patient is seen prior to
tumor excision. The diagnosis is verified, the likely extent of
excision and reconstruction is discussed, and the treatment
options are outlined. Preoperative medical clearance can be
obtained, if necessary. Operative time is scheduled for the
future. Excision is performed and a follow-up appointment is
made to evaluate the defect after tumor clearance. During the
post-excisional consultation, the true extent of the defect is
confirmed and anatomic and aesthetic losses are defined.
Reconstruction follows within 48–72 h. Because the extent of
the defect has been defined prior to repair, the patient under-
stands the requirements of reconstruction and maintains an
ongoing informed participant in his/her care.
Such coordinated excision and repair provides an opportu-
nity to think, plan, and discuss options with the patient in a
leisurely manner prior to entering the operating room. A
surgical plan is developed preoperatively – decreasing patient
and surgeon anxiety and ensuring the best result. Because
tumor clearance has been confirmed prior to repair, the length
of anesthesia and operative times are shortened. Most impor-
tantly, disruption of the operative schedule and intraoperative
decision making are minimized.
Diagnosis/patient presentation/selection
The preoperative consultation should clarify the diagnosis,
define the anatomic and aesthetic deficiencies, ensure a
healthy wound and patient, provide patient education, instill
confidence and the patient’s participation, formulate a surgi-
cal plan, and identify donors, methods, and staging. Medical
history and physical examination are evaluated with special
emphasis on the etiology of the nasal injury, disease remis-
sion, or cancer clearance. Facial photographs, combined with
calibrated photographs and normative facial measurements,
clarify anatomic and aesthetic injury, old scars, landmark
malposition, injury to available donor sites, and provide
measurements which are useful intraoperatively. In complex
three-dimensional (3D) injuries, a facial moulage is obtained
preoperatively and a clay model of the desired result designed.
This allows the surgeon to intellectually visualize the dimen-
sion and contours which require replacement. Prior pathologic
exams and old operative reports are examined. Facial X-rays,
computed tomography (CT) scans, or magnetic resonance
imaging (MRI) are occasionally employed to clarify bony and
soft tissue injury to the midface when rebuilding composite
defects of the nose and cheek.
Planning an aesthetic nasal
reconstruction
The traditional approach
Traditionally,22,25 the defect determined the repair. Surgeons
“filled the hole” to obtain a healed wound. So the design and

128
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
tissue transfer are clearer with the ideal normal in mind (Fig.
6.1, Box 6.1).
In the latter half of the twentieth century, Gonzalez-Ulloa28
divided the face into regions, based on skin thickness. Millard29
envisioned major facial landmarks as “units” and recom-
mended replacing them in their entirety with “like” tissue of
similar color and texture to avoid a patch-like repair. Burget
and Menick30 divided the nose and face into “subunits”, based
on skin quality, border outline, and 3D contour.
The concept of peripheral and central
facial units
The face can be divided into peripheral and central units areas
of characteristic skin quality, border outline, and 3D contour.
This regional unit concept guides clinical observation and
treatment recommendations.22,25
Peripheral units
The forehead and cheek are peripheral facial units. Like a
“picture frame”, they lie at the periphery of the face and
receive secondary intention. Their surfaces are largely flat and
expansive and their border outlines variable, according to
hairline and eyebrow position. Because their borders are not
visible in all views, their borders can only be incompletely
compared to the contralateral normal side for symmetry or
outline. Because the peripheral units are less exact and con-
stant, their repair is less demanding and of secondary impor-
tance. Skin quality, not outline or 3D contour, determines
success.
A moderate forehead defect can be allowed to heal second-
arily. The resulting shiny, flat scar, supported by the underly-
ing rigid bony platform of the skull, blends into the normal
shiny, tight surface of the forehead without significant distor-
tion or malposition of adjacent landmarks. Rarely, a skin graft
may be used to replace the entire forehead unit or a lateral
subunit, after discarding any residual skin within the unit.
The uniform, shiny quality of the skin graft simulates the
expected quality and contour of the entire forehead unit or
The presence and number of scars determine the final
result. Place incisions in existing scars, minimize scars,
fear scars
A poor facial repair is identified by incorrect dimension,
volume, position, and contour, not by the presence of scars.
Scar can be effectively camouflaged by positioning them in
the joins between subunits.
Place a supportive framework and debulk excess tissue
secondarily after the soft tissues have healed
Traditionally, cover and lining have been replaced without
support to avoid the risk of extrusion and infection. Occasion-
ally, flimsy cartilage strips were placed within a prefabricated
flap over a skin graft. Months later, bone and cartilage grafts
were placed as crude cantilevered grafts to lift the tip and
dorsum.
Unfortunately, unsupported soft tissues are rapidly dis-
torted by gravity and tension and become fixed by scar. Late
re-expansion with secondary cartilage grafts and soft tissue
“thinning” may not be successful.
One hole – one flap – and (often) one operation
It is difficult to reproduce the delicate 3D character of multiple
facial units with a single flap. A single flap often fails to
supply enough skin to resurface 3D contour. Myofibroblasts
within the bed of scar under the flap contracts, drawing the
single flap into a dome-like pin cushioned mass. For that
reason, it may be preferable to repair individual facial units
with separate grafts and flaps of exact dimension and skin
quality.
The modern approach to nasal reconstruction
A healed wound, tissue survival, or the replacement of ana-
tomic layers are necessary, but not sufficient, to restore a
normal appearance and function. Aesthetic results depend
upon the surgeon’s and patient’s choices.22,25 The modern
approach relies on the visualization of the “normal” to deter-
mine what is missing, both anatomically and aesthetically.27
This regional unit approach emphasizes the judicious choice
and modification of recipient and donor tissues to provide for
the exact replacement of facial units. The principles of facial
reconstruction have switched from a wound perspective (how
big, how deep, anatomy, and flap blood supply) to a visual
one. The mature surgeon, with training and experience, “sees
the future”. He or she conceptualizes among available options
what will work, while visualizing the desired result. A plan
is formulated, principles outlined, and techniques and
methods chosen.
Fortunately, although each defect is different, all repairs are
simplified because the “normal” is unchanging. The “normal”
nose is visually defined by its dimension, volume, position,
projection, platform, symmetry, and expected skin quality,
border outline, and 3D contour. Major facial landmarks are
described as Regional Units – adjacent topographic areas of
characteristic quality, outline, and 3D contour. Often, the
contralateral normal remains as a visual standard for com-
parison. If not, the ideal is the guide. A unit approach helps
the surgeon conceptualize the goal, define the requirements
of repair, balance options, and measure the success of the
result. Goals, priorities, stages, materials, and method of
BOX 6.1  Gillies’ and Millard’s “ten commandments” of plastic
surgery. (Reproduced from Gillies HD, Millard DR. The Principles
and Art of Plastic Surgery. Boston: Little Brown; 1957.)
• Observation is the basis of diagnosis.
• Diagnose before you treat.
• Make a pattern of the defect and a plan.
• Replace the normal in the normal position and retain it there.
• Do something positive.
• Treat the primary defect first. Do not let the secondary defect
endanger the final result.
• Borrow from Peter to pay Paul, if Peter can afford it.
• Losses must be replaced in kind.
• Never throw anything away, unless you are sure you do not
want it.
• Never let routine methods become your master.
• Never do today what you can honorably put off until tomorrow.
When in doubt, do not.

129
Planning an aesthetic nasal reconstruction
A
B
Lateral genu
Medial genu
Caudal septum
Septal angle
Nasal bone
Frontal process of maxilla
Upper lateral
cartilage
Alar cartilage
lateral crus
middle crus
medial crus
Nasolabial angle
Nasal
lobule
Tip
lobule
Supratip region
Nasofrontal
(surface) angle
Glabella
Nasal sidewall
Alar groove
Alar lobule
Nasolabial fold
and crease
Nostril sill
Triangle of upper lip
Soft triangle (facet)
Fig. 6.1  Anatomy, surface contour, and subunits.
C
Dorsum
Sidewall
Tip
Ala
Soft triangle
D
Thin skin zone
Thin skin zone
Thick skin zone
subunits and its peripheral scars are masked along the hair-
line, brow, or contour lines between the lateral and central
forehead subunits.
Most often, the lax and excess adjacent skin within
the cheek is shared by resurfacing the defect with a non-
subunit rotation advancement flap. The Subunit Principle
is rarely applied when resurfacing the cheek or forehead.
Enlarging the wound so that the entire forehead or cheek
is recovered with one flap is impractical due to the paucity
of available donor excess and the unreliability of flap
blood supply.
Central units
The central midfacial units of the nose, lip, and eyelids require
a different reconstructive approach. The principles of regional

130
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
3. The amount of cartilage material required to support the
soft tissues may be increased.
4. Patient morbidity may increase if regional flaps or
cartilage grafts are needed.
However, when applied appropriately, the final result may
be significantly improved. It should be emphasized, however,
that a good result does not depend on any one surgical
maneuver. It reflects a series of choices, methods, and tissue
manipulations that transfer a correctly thinned covering flap
which blends into neighboring tissues, establishes a 3D
contour, and replaces missing tissues in exact dimension and
outline. Resurfacing a facial defect as a unit can be helpful,
but it is only a single tool.
Use the contralateral normal or the ideal as a guide
The apparent defect may not reflect the actual tissue loss. Due
to edema, tension, gravity, scar, or past repair, the wound may
be larger, smaller, or altered in shape. The surgeon must use
the contralateral normal – the opposite ala, hemi-tip or hemi
nose, and hemilip subunit to design a foil template that reflects
the size and shape of the missing subunit. If the contralateral
normal is absent, a template can be designed from an ideal
clay model, based on a moulage of the patient’s face, or a
template can be designed from another normal face.
Replace tissues in exact dimensions and outline
If a flap is larger than the defect, its bulk pushes adjacent
landmarks outward, creating malposition and asymmetry.
Excess skin also obscures the surface details created by the
underlying support. If the flap is smaller than the defect,
neighboring structures are pulled inward. The tension also
collapses underlying cartilage grafts. Exact 3D patterns are
designed to fit the needs of the “true” tissue defect, rather than
a wound distorted by edema, tension, scar, or prior repair.
Employ templates
An exact foil template of the contralateral normal or ideal is
used to design flaps and support grafts. Such templates
determine the size of the flap or cartilage graft, the shape of
its border and the dimension or the position of facial land-
marks (alar base, nasolabial fold, or alar crease).
Choose ideal donor materials and employ an ideal method
of tissue transfer
Millard’s admonition to use “like for like” applies. Use lip for
lip, cheek for cheek, and a forehead or nasolabial flap for nasal
resurfacing. Distant tissues are employed for lining, to fill
dead space, create a facial platform, or vascularize an ische-
mic, contaminated, or radiated wound. However, regional
skin should be used to replace facial skin because distant skin
does not match the facial skin quality.
Understand wound healing and tissue transfer
Traditionally, the method of tissue transfer was chosen based
on the vascularity and depth of the defect. Skin grafts were
employed to resurface well vascularized superficial defects,
when skin and a small amount of subcutaneous tissue are
missing. Skin flaps were used to supply bulk to a deep defect
or cover a poorly vascularized recipient site, a wound with
exposed vital structures, or exposed or restored cartilage and
bone.
unit reconstruction apply primarily to repair central facial
defects, not the peripheral units.
The nose has a fixed border outline, a 3D shape, and contra-
lateral symmetry that must be maintained. Although skin
quality is important, landmark outline, contour, and sym-
metry are of greater importance. The central units are seen in
primary gaze and demand the highest priority of repair.
The dimension and outline of the nasal wound may be
altered by discarding additional residual normal skin within
the subunit to resurface the defect as a unit. Large nasal
defects are reconstructed with regional transposition flaps of
exact dimension and outline to avoid tension, collapse, or
distortion of adjacent mobile landmarks. The external skin
surface must be shaped in 3D with cartilage grafts for support
and contour.
Principles of regional unit repair25,27
■ Human beings wish to look normal.
■ The normal is defined by 3D contour, border outline, and
skin quality which describe Regional Units. They do not
correlate with wrinkle or resting skin tension lines.
■ The nasal unit consists of the tip, dorsum, columella, and
paired alae, sidewalls, and soft triangle subunits.
■ Restore units, do not fill defects.
■ If a defect, within part of a central unit, is filled without
regard to the unit outline, the tissue replacement may
appear as a distracting patch within the subunit. The
reconstructive goal must be to restore the character of the
unit, rather than simply fill the “hole”.
■ Alter the wound in site, size, outline, and depth. Discard
adjacent normal tissue within convex nasal subunits to
improve the result.
When part of a central convex nasal unit is missing, it is
often useful to resurface the entire unit or subunit, rather than
simply patch the defect. The wound’s dimension, outline, or
depth may be altered. Subunit resurfacing positions scars so
that they are camouflaged within the joins between subunits.
More importantly, myofibroblasts lie in the recipient bed
under a transferred flap and contract, causing the transposed
skin flap to rise above the level of adjacent skin. When an
entire convex subunit is resurfaced, the pin cushioned flap
shrink-wraps around the underlying cartilage framework,
augmenting, rather than distorting, the contour of a convex
subunit. Residual tissue within the subunit may be discarded
to enlarge the wound. Or the defect may be decreased in
size by local advancement rotation flaps, or changed in
border outline by a combination of excision and tissue
rearrangement.
The subunit principle22,30
If a defect of a central convex subunit, such as the tip or ala,
is greater than 50% of the subunit, discard adjacent normal
tissue within the subunit and resurface the entire subunit,
rather than merely “patching the hole”.
The consequences of the Subunit Principle are:
1. The defect may be enlarged and the donor requirement
increased. A larger defect may preclude closure with
local tissue and necessitate a regional flap repair.
2. The number of stages and the complexity of the repair
may be increased.

131
Planning an aesthetic nasal reconstruction
neous bed with quilting sutures. The wound is closed.
Although a new incisional scar is created, it lies hidden in the
border outline of the newly contoured subunits. Visually, the
new scar is hidden within the expected contour depression
between units.
Employ surgical staging to advantage
Each surgical stage is an opportunity to recreate the defect,
return normal to normal, ensure viability, prepare excess
tissue for other uses (hingeover lining flaps, soft tissue bulk,
etc.), surgically delay, prefabricate, transfer, and modify
tissues by debulking or shaping, add or alter support grafts,
or improve imperfections, and treat complications or second-
ary priorities.
Consider a preliminary operation
Often, the extent of deformity is obscured by secondary
healing, prior skin grafts, or flaps. A preliminary operation,
prior to formal nasal reconstruction, can be helpful. The defect
is recreated and residual tissues returned to their normal
position. The dimension and position of the defect and the
required tissue replacements are more accurately defined.
Although past history, physical examination, old operative
reports, or radiographs may provide information, the extent
of the true defect may only become apparent after recreating
the defect. Excision of scar or soft tissue bulk can open an
occluded airway. Residual local tissue or adjacent regional
flaps can be positioned for later use or surgically delayed to
maximize blood supply, especially when scar lies within the
territory or injury to the flap’s pedicle is suspected. Ischemic
or chronically infected tissue may be debrided. Immature
tissues may revascularize, soften, and stabilize. Defects of the
lip and cheek may be repaired, establishing a stable platform
on which to place the nose at a later date. If indicated, the
wound can be biopsied to ensure complete clearance of tumor
or immune disease remission.
When a defect is complex, the patient may be anxious and
the surgeon uncertain of tissue needs or available options. The
diagnosis may need clarification, the wound may need prepa-
ration, and the problem may need to be analyzed to prepare
a plan.
Classification of defects
Nasal defects are classified into small, superficial, large, deep,
or composite defects.22,25 The difficulty of repair will be deter-
mined by the site, size, and depth of injury.
A “small defect” is less than 1.5 cm in diameter. A skin graft
can be employed to resurface larger defects. But if the defect is
larger than 1.5 cm, local flaps are precluded because there is not
enough residual skin to “share” over the entire nasal surface
without excessive closure tension and landmark distortion.
“Superficial defects” include skin and a small amount of
underlying subcutaneous fat and nasalis muscle. Vascularized
soft tissue remains in the depth of the wound to revascularize
a skin graft or can be resurfaced with a flap. Although a small
defect may be allowed to heal secondarily, if periosteum or
perichondrium is missing, a skin graft is precluded and a
vascularized flap will be required.
“Adversely located defects” are those whose position neces-
sitates a regional flap for cover. If the defect is closer than 0.5
to 1 cm of the nostril margin, local flaps will distort the tip
Postoperatively, skin grafts are typically shiny, atrophic,
and hypopigmented or hyperpigmented. Even though a skin
graft donor may match the color and texture of the recipient
site, the transient ischemia associated with skin graft “take”
leads to unpredictable skin color and texture changes,
and full-thickness skin grafts shrink modestly but do not
trapdoor.
In contrast, a flap maintains its own perfusion and retains
the skin quality of its donor site. However, the scar between
the flap and the recipient bed contracts, which leads to pin
cushioning.
Flaps often develop a convex surface shape. Therefore, skin
grafts are best employed to resurface flat or concave recipient
sites, such as the nasal side wall, while skin flaps are used to
resurface convex surfaces, such as the tip or ala subunits.
When an entire convex subunit is resurfaced with a flap as a
unit or subunit, wound healing and tissue transfer are har-
nessed and pin cushioning contributes to the desired contour.
Build on a stable platform
Unfortunately, the lip/cheek platform may shift postopera-
tively due to resolution of edema, gravity, tension, and scar
contraction. The larger and deeper the defect, the greater is
the risk. If the lip/cheek platform is unstable and the nose is
reconstructed at the same operative procedure, the nose may
be dragged inferiorly and laterally over time.
Although a small superficial defect of the nose, cheek, and
lip can often be rebuilt during a single stage, large deep
defects of the cheek and lip are more reliably reconstructed
during a preliminary operation which re-establishes a stable
platform. Then the nose is built secondarily at a later stage.
Restore the subcutaneous framework of hard and
soft tissue
A nose looks normal because it has a nasal shape. Primary
and delayed primary support grafts should be placed to
restore missing cartilage and bone which support, shape, and
brace cover and lining against collapse and contraction.
Although the alar lobule and soft triangle normally contain
no cartilage, cartilage must also be placed along the nostril
margin. Alar batten grafts brace the alar rim and prevent
constriction inward, contraction outward, and airway col-
lapse. Precise soft tissue excision can also add 3D shape by
improving overall nasal contour during each surgical stage.
Secondary placement of cartilage grafts is less effective, once
soft tissues are contracted by scar.
Disregard old scars
To avoid additional incisional scars, bulky flaps are often
“thinned” secondarily, during late revision, by elevating the
peripheral edges of the flap through its border scar. However,
it is frequently preferable to disregard old scars and add
additional incisions.
Using accurate templates, based on the contralateral normal
or ideal, the desired 3D concavity of the alar crease or naso-
labial fold are marked with ink. Once the ideal landmark
position is incised and the wound edges on either side of the
“new” incision are elevated. Under direct vision, the underly-
ing soft tissue is sculpted in three dimensions to create a flat
sidewall, a round ala, a full medial cheek, etc. The overlying
skin is then reapproximated to the newly contoured subcuta-

132
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
can be divided into areas of thin smooth skin and thickly
pitted skin. Note that the zones of skin quality do not corre-
spond to the nasal units, which are defined by contour.
In the superior half of the nose, dorsal and sidewall skin is
thin, smooth, pliable, and mobile. A modest excess of skin is
present, which permits primary closure or a local flap to close
small defects without distortion of adjacent mobile landmarks.
A modest amount of skin can also be recruited from the cheek
to resurface a small sidewall or ala defect. Although a simul-
taneous rhinoplasty, hoping to decrease the size of the nasal
skeleton and relatively increase the available skin, has been
recommended to ease the closure of small defects in a large
nose, it is rarely helpful.
The inferior half of the nose is covered by a zone of tight
skin, pitted with sebaceous glands, and adherent to the under-
lying deep structures. No excess is present. This thick skin
zone begins in the alar groove, crosses 5–10 mm above the
supratip region, and extends inferiorly towards the caudal
borders of the tip and alar subunits. About 2–3 mm above the
alar margins and a few millimeters below the outermost point
of the tip and onto the columella, the skin thins and loses its
sebaceous quality. The lower half of the infratip lobule,
including the soft triangle and columella, is covered by thin,
but adherent skin fixed to the underlying structures. There is
no excess within the inferior nose and the tip and alar margins
are mobile and easily distorted by contracting scar or inac-
curate tissue replacement.
Restoring nasal cover
Small, superficial defects
Healing by secondary intention
The body responds to injury by epithelialization, granulation
tissue, and myofibroblast contraction. The process is simple,
inexpensive, somewhat slow, but often satisfactory.
Healing by secondary intention is used for wounds created
by a destructive process which preclude primary closure.
These include electrodessication and curettage or those asso-
ciated with wound dehiscence, infection, or necrosis. To avoid
further injury due to desiccation or trauma, secondary healing
is avoided if vital deep structures are exposed in the base of
the wound.
No net gain in tissue occurs with secondary healing. Wound
contraction progresses to the degree that adjacent tissue can
be pulled into the defect. The residual gap is filled with col-
lagen covered with a shiny adherent, thin layer of epidermis,
containing few melanocytes or skin appendages. The result is
a pale, shiny, flat, white scar.
Secondary healing is employed for defects which lie within
a flat or concave nasal surface, at a distance from mobile
landmarks, especially when they lie within sun or radiated
injured skin where imperfections of skin quality due to spon-
taneous healing are less apparent.
A small superficial defect of the flat tight dorsum, sidewall,
or deep alar crease may heal satisfactorily by secondary inten-
tion. However, imperfections in color or texture or contour
depressions are visible in the thicker skin of the tip and ala.
The mobile tip and nostril margins are also at risk for distor-
tion due to scar contracture. Despite limitations, almost
any wound will heal spontaneously, if medical illness, cost,
and nostril rim. Local flaps do not reach the infratip lobule or
columella. A regional flap will be needed to resurface adversely
located defects, even though the wound is not necessarily
large.
“Large defects” are greater than 1.5 cm in size. Insufficient
skin remains over the residual nose to redistribute with a local
flap. Skin must be added by transferring a skin graft or excess
cheek or forehead.
“Deep defects” are those in which the underlying support or
lining is missing.
If a cartilage graft is needed or lining is missing, a skin graft
or local flap cannot be employed. Even in the ala which
contains no cartilage, if significant alar skin and underlying
compact fibro-fatty middle layer are absent, cartilage support
must be placed.
A skin graft will not “take” over bare cartilage grafts. And
a local flap is precluded because delicate cartilage grafts col-
lapse under the wound tension associated with local flaps
which share residual tissue over the nasal surface.
So although a small rim defect can be closed with a com-
posite skin graft, significant full-thickness defects require a
vascularized regional flap for cover.
“Composite defects”31 extend from the nose onto the adjacent
cheek and upper lip to include individual nose, cheek, and lip
units which differ visually, anatomically, and functionally.
Quality, outline, and contour are different for each facial unit.
The degree of tissue loss varies from unit to unit and the need
for cover, lining, support, soft and hard tissue will be
different.
The simplest solution is to “fill the hole”, replacing missing
skin and soft tissue with a single flap. But it is difficult to
reproduce the delicate 3D character of a composite defect with
a single flap. Geometrically, the shortest distance between two
points is a straight line and a single flap often takes a “surgical
shortcut” and fails to provide enough skin to restore 3D
contours. Scar contraction of a defect which includes multiple
units draws a single flap into a domelike mass, outlined by
patch-like peripheral scars. Using separate grafts or flaps for
each facial unit better positions scars in the expected joins
between landmarks and helps control flap pin cushioning.
The repair of nasal defects –
treatment options
Although “simple” at first glance, small and superficial defects
are difficult to repair. Surgeons and patients fail to appreciate
the complexity of nasal contour, the paucity of excess tissue,
the difficulty of matching the skin in color and texture,
and the risk of distorting the residual mobile tip and nostril
margins. The time, trouble, morbidity, donor and recipient
scars, number of stages, time to wound maturity, and the cost
must be balanced against the likelihood of secondary defor-
mity. Many options are available.
Understanding nasal skin quality
The nose is covered by skin and an underlying layer of sub-
cutaneous fat and nasalis muscle which lay over a rigid bony
elastic framework of cartilage and fibrofatty support. However,
the quality of the skin is not uniform, unless atrophic due to
old age, sun injury, or radiation injury. In the normal nose, it

133
The repair of nasal defects – treatment options
However, traditional skin grafts, within the thick skin zone of
the tip and ala, often appear as depressed, shiny, off-colored
patches unless the skin of the recipient site is atrophic due to
sun injury or radiation.
Preauricular and postauricular skin grafts
Hairless preauricular skin is a good donor site. A strip of skin
2–2.5 cm wide can be harvested. Larger grafts may transfer
fine vellus hair in women or bearded skin in men. Postauricu-
lar skin can be harvested from the back of the ear and mastoid,
across the postauricular crease. In unusual circumstances, the
entire posterior surface of the ear can be taken and the donor
site skin grafted with more distant skin. Postauricular skin
may remain red. The hairless preauricular patch between the
tragus and sideburn provides a better match, especially when
applied to the dorsum, sidewall, or columella. Supraclavicular
skin looks brown and shiny.
The full-thickness forehead skin graft (Figs. 6.2 & 6.3)
Forehead skin is acknowledged as the best match to replace
nasal skin. Although not traditionally transferred as a skin
graft, forehead skin is useful for resurfacing small superficial
defects, especially of the tip and ala. Forehead skin and its
underlying compact fibrofatty subcutaneous layer are thicker
and stiffer than other donors. Significant amounts of soft
tissue can be carried with the graft, permitting the replace-
ment of the deeper soft tissues. Forehead skin grafts revascu-
larize normally, with progressive changes in color from white
to blue to pink. A good take is routinely expected. However,
when failure seems eminent, unlike grafts harvested from
lifestyle, or patient disinterest precludes a more formal repair
initially.
Primary repair
Because a modest excess of skin is present in the more lax
upper two-thirds of the nose, primary repair may be possible
if the defect is less than 5–6 mm. Because no extra skin is
available in the thick adherent skin of the tip and ala, primary
closure is avoided to prevent distortion and wide depressed
scars.
Skin grafting
Skin grafts have many advantages.22,25 No new scars are added
to the nasal surface, and the amount of locally available tissue
is not a limiting factor. Skin grafts are typically harvested from
preauricular, postauricular, or supraclavicular donor sites.
Forehead grafts are best for the tip and ala.
However, a skin graft must lie on a well vascularized bed
to ensure “take” and will not reliably survive when placed on
denuded cartilage or a cartilage graft. A skin graft, placed
over a narrow primary cartilage graft, may revascularize by
the bridging phenomena. The size of the cartilage graft must
be limited. Complete or partial skin graft necrosis may occur.
The aesthetic result of skin graft is unpredictable. Because
of the transient ischemia which accompanies skin graft trans-
fer, the quality of donor skin deteriorates. Skin grafts often
appear pale, smooth, and atrophic. A full-thickness skin graft
may blend satisfactorily into the relatively smooth atrophic
upper nose within the thin skin of the dorsum and sidewall.
Fig. 6.2  Forehead skin graft technique.
A
B
C
1
3
2
4
5
6
Quilting
sutures
Surgical sponge
Petroleum gauze

134
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
skin edge and a vascular bed, removing old scar or granula-
tion tissue.
The graft is elevated with subcutaneous fat which is
removed from its undersurface with curved scissors, but the
graft is not necessarily thinned to dermis. The thickness of
skin graft and its underlying fat matches the depth of recipi-
ent site. The graft is laid on the prepared bed, trimmed, and
inset with a single layer of fine sutures, peripherally after
placing quilting sutures through the skin graft and into the
recipient bed to prevent lateral motion. A layer of antibiotic
ointment and fine gauze is applied, followed by a soft foam
bolus.
Traditionally, individual bolus tie-over sutures are fixed to
the wound edge and tied to each other over the bolus.
However, it is more efficient to tie a single 4-0 or 5-0 polypro-
pylene suture about 5–10 mm from the wound edge and then
crisscross back and forth across the bolus in a running fashion
until tying the suture to itself. The surgeon later clips the
suture in one or two areas to easily remove the dressing. The
stent dressing immobilizes the skin graft postoperatively and
reinforces the quilting sutures. However, it is not a “pressure”
dressing and should not be applied to prevent hematoma.
Initially, the skin graft appears white. Over several days,
perfusion increases and the graft changes color from blue to
visibly pink. Although the bolus can be removed earlier, it is
other sites, early separation does not occur. A hard and tightly
adherent eschar develops. It may remain fixed to the underly-
ing tissues for 4–6 weeks. After spontaneous separation, the
surgeon often finds that the wound is healed, filled, and the
aesthetic result good. One to 1.5 cm of forehead skin is easily
harvested below the frontal hairline with primary closure of
the donor site. The scar is usually excellent and easily covered
by hair.
Skin graft technique
A skin graft must be placed on a vascular bed to ensure
“take”. It will not survive if tented across the defect or sepa-
rated by hematoma or seroma. It must be immobile to allow
the development of vascular connections to the recipient site.
Because excessive coagulation of the recipient site is
avoided, it is often helpful to delay skin grafting for 10–14
days to allow spontaneous separation of burn eschar and
allow tissue to granulate. The recipient site is protected from
desiccation by daily cleansing with soap and water and
antibiotic or petrolatum ointment to prevent drying. The skin
graft is then applied as a delayed primary graft, avoiding
exposure of the underlying cartilage during preparatory
debridement.
A pattern is made of the defect. The margins and base of
the wound are freshened to create a clean, sharp, right angle
A
B
C
Fig. 6.3  (A–E) Small superficial
nasal tip defect resurfaced with
full-thickness forehead skin graft.
D
E

135
The repair of nasal defects – treatment options
As the dorsal flap slides caudally, a dog-ear is excised inferi-
orly. Ideally, its borders are planned to lie along the dorsal
sidewall junction. The inferior aspect of the flap’s border may
be visible as a depressed scar crossing the smooth surface of
the tip unit. Like all local flaps, the larger the defect and the
closer it lies to the nostril margin, the more likely the tip or
rim will be distorted by tension or displaced by poor design.
The geometric bilobed flap
The bilobed flap is recommended for defects within the thick,
stiff skin of the inferior nose.
The bilobed principle is applied.37–39 Skin is shifted from an
area of excess to an area of deficiency by designing the first
lobe adjacent to the tip or alar defect. A second lobe, which
lies at a distance in an area of tissue availability within the
upper nose, is outlined in continuity. As the primary lobe
shifts to repair the defect, the secondary lobe resurfaces the
defect from the primary lobe. The tertiary defect from the
second lobe is closed primarily, within the area of excess.
Traditionally, bilobed flaps were designed with a 180° rota-
tion. This created large dog-ears. The dog-ear excision subse-
quently narrowed the flap’s vascular base, jeopardizing blood
supply. Macgregor, and later Zitelli, developed a geometric
design to decrease the flap’s rotation to 90–100° and incorpo-
rated a dog-ear excision which did not diminish blood supply.
It is useful for defects measuring 0.5–1.5 cm in the inferior
nose.
The rotation-advancement flap can be oriented anywhere
around the defect but the pedicle base must be positioned
away from the nostril margin to prevent distortion. The
second lobe must also lie within the loose excess skin of the
upper sidewall or dorsum. It can be based medially or later-
ally. The pattern should not extend onto the cheek or lower
lid.
Several rules apply:
1. The pivot point is established at a distance from the
defect equal to one half of the defect’s diameter. The
flap is based laterally for tip defects and medially for
defects of the alar lobule. The farther the pivot point is
away from the defect, the larger the flap. Sharing the
same pivot point, the circumferences of a larger outer
and a smaller inner concentric circle are drawn onto the
nasal skin. The circumference of the outer circle is
outlined at a distance three times the radius of the
defect. The second smaller inner circle is marked to
equal the distance from the pivot point to the center of
the initial defect (the diameter of the defect). Because
the nasal surface is round, not flat, a strip of foil or bent
paper ruler, rather than a straight ruler, is used as a
template which is rotated around the pivot point, until
the circumference of both concentric circles are
determined.
2. An exact pattern of the circular nasal defect is
positioned immediately adjacent to the defect, along the
outer concentric circle. The first lobe should replace the
defect exactly, to prevent tip or alar rim distortion on
closure. Because the second lobe lies within the more
mobile skin of the upper nose, it can be designed
slightly smaller than the defect. The secondary defect
can be partially closed by recruitment of lax adjacent
skin within the upper nose. A dog-ear excision, which
best left in place for 1 week. If the defect is repaired delicately
with fine sutures and without tension, suture marks do not
occur.
Local flaps
Unlike a skin graft, the quality of the skin transferred as a
vascularized flap maintains its original color and texture
quality. A skin flap is also thicker than a graft and may better
supply missing subcutaneous bulk.
There is no excess within the “thick” skin zone of the tip
and ala. But excess skin is present within the more mobile
upper “thin” skin zones of the dorsum and sidewall.
Local flaps do not add new skin to the nasal surface. They
share the available, but limited, excess within the upper nose.
Guidelines, applicable to nearly all local nasal flaps, should
be followed carefully:
■ If the defect is larger than 1.5 cm, the remaining skin
surface is insufficient to redistribute over the nasal
skeleton without excess closure attention and distortion
of mobile landmarks.
■ Local flaps are used for small superficial defects, greater
than 5–10 mm from the nostril margins and above the tip
defining points. Commonly described local flaps will not
reach into the infratip area.
Unfortunately, hoping to avoid the morbidity or stages
required by regional flaps, these rules are often broken,
leading to nasal collapse and tip and alar margin malposi-
tions. In such instances, it would be better to allow the wound
to heal secondarily or apply a skin graft.
The single lobe transposition flap (Fig. 6.4)
A modest amount of excess mobile and lax skin is available
within the superior nose. A single lobe transposition flap,
designed as a Banner or Romberg flap, is useful for small
defects.32,33 These flaps transpose skin through an arc of 90°,
taking excess from one axis to fill a deficiency in another.
Because the skin is relatively mobile, available, and lies at a
distance from the nostril margins, these small local flaps are
unlikely to distort the tip or alar margin. However, if the flap
donor scar crosses the bridge transversely, a depressed scar
may become visible on profile view. Single lobed flaps are not
useful in the inflexible thick skin of the tip or alar, which shifts
poorly. Deforming dog-ears or displacement of adjacent
mobile landmarks is common.
The dorsal nasal flap
The dorsal nasal flap elevates skin, subcutaneous tissue, and
muscle just above the perichondrium and periosteum and
slides excess from the glabella towards the tip. The flap is best
applied to defects within the dorsum and superior tip
subunit.34–36 It is vascularized from facial and angular vessels
along the sidewall and medial canthus. Closure is facilitated
by advancing cheek skin upward onto the nasal sidewall. The
dorsal nasal flap can resurface the nasal tip and dorsum and
parts of the ala or sidewall with local skin. Unfortunately, it
slides thicker glabellar skin and soft tissue downward onto
the nasal sidewall near the medial canthus where a mismatch
in skin thickness may create an iatrogenic epicanthal fold. The
depth of the radix may be obliterated, effacing the nasal root.
Recent modifications have eliminated the glabellar extension.

136
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
extends lateral to the outer circle, is added to the second
lobe.
A dog-ear excision is marked from the defect to the
pivot point, creating space for the flap to rotate and
advance. The flap rotates less than 100° with a wide
base to maintain flap blood supply.
3. The dog-ear extending from the defect of the pivot point
is excised. The first and second lobes, including the
distal dog-ear, are elevated above the periosteum. The
flap includes skin, subcutaneous fat, and nasalis muscle.
Residual normal nasal skin is undermined widely over
the perichondrium and periosteum.
4. Significant pin cushioning is infrequent with the bilobed
flap, if it is carefully repaired, in layers. The tertiary
defect, in the more mobile upper nose, is first closed in
layers. This pushes the flap inferiorly, preventing the
B
Bilobed flap
90˚
A
Single nasal flap
Fig. 6.4  (A–C) The single, bilobed, and dorsal nasal flaps.

137
The repair of nasal defects – treatment options
Although planned as a single-staged repair, it is not uncom-
mon to revise scars, recreate the obliterated alar crease, or
reposition the nostril margin.
The geometric bilobed flap is effective, but it should be
limited to defects of the tip, which are less than or equal to
1.5 cm in diameter and that lie more than 1 cm away from
the nostril margin. This precludes its use for significant alar
defects. Despite the relatively small size of these defects,
the technique is time-consuming, the dissection exten-
sive, scars multiple, swelling significant, and distortions
common.
The one stage nasolabial flap (Fig. 6.5 )
The one-stage nasolabial flap can resurface defects of the nasal
sidewall and ala, up to 2 cm in size.25 Excess skin of the medial
cheek, lateral to the nasolabial fold, is transferred as a random
pattern extension of an advancing cheek flap. Unlike local
flaps which redistribute residual nasal skin, this technique
“adds” regional cheek skin to the nasal surface. This mini-
mizes risk of landmark distortion and permits the use of alar
support grafts without fear of collapse due to excessive
tension.
Fig. 6.5 appears online only.
1. The sidewall and alar subunits are outlined in ink. Alar
subunit excision is not performed but skin, which
remains between the defect in the inferior nostril rim,
can be excised, enlarging the defect inferiorly to the
nostril margin. This positions the scar along the nostril
border and improves the flap’s blending with the
recipient site. The underlying lining is braced with a
septal or ear cartilage graft to prevent collapse or
retraction of the nostril margin. The ends of the cartilage
graft are buried, medially and laterally, in subcutaneous
pockets along the rim and fixed with percutaneous 5-0
polypropylene sutures. The cartilage graft is quilted to
the underlying lining to fix the support graft and brace
the nostril margin.
2. The nasolabial crease is marked and a pattern of the
defect is positioned exactly adjacent to the nasolabial
fold so that the late cheek scar lies exactly in the
nasolabial crease. A dog-ear excision is marked
inferiorly, distal to the template. Ensure that the sliding
cheek advancement has adequate length to swing and
correctly position the nasolabial extension onto the nasal
defect. The most important flap dimension is width,
which should equal the width of the defect. The distal
margin of the flap will be trimmed during wound
closure and does not need to be predetermined. The flap
is elevated in continuity with the distal dog-ear. The
superior lateral incision for the alar or sidewall flap
extension should not extend higher than the alar
remnant that must be “jumped over” to reach the
recipient site. A higher incision is unnecessary and may
impair blood supply.
3. The nasolabial skin extension and the cheek flap are
undermined, with a few millimeters of subcutaneous fat
for 3–5 cm. The cheek is advanced, fixing its underlying
raw surface to the deep tissues along the nasal facial
groove. This suture fixation advances the cheek flap,
closes the donor defect, and restores the nasofacial
sulcus. It eliminates lateral and vertical tension on the
C
Fig. 6.4, cont’d
tendency of the flap to return to its donor site. The
primary lobe, after appropriate “thinning” so that its
skin surface will match the level of the adjacent normal
skin, is transferred to the primary defect. The secondary
lobe is transposed to fill the gap created by the first
and its distal dog-ear is excised to fit the secondary
defect.
Unfortunately, postoperative tip or nostril distortion is
common, especially when the defect lies within the tip or ala.

137.e1
The repair of nasal defects – treatment options
A
B
C
Fig. 6.5  (A–E) Nasal defect after excision of basal
cell carcinoma of the medial ala and tip resurfaced
with one stage nasolabial flap. No revision.
D
E

138
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
at the upper end of the nasolabial crease. A triangular dog-ear
excision is designed distally along the nasolabial fold.
Residual skin within the alar subunit is discarded. The
contralateral alar template is used to design a cartilage support
graft – most often of conchal cartilage – with the correct
dimension and nostril margin outline. The graft’s medial and
lateral ends are buried in subcutaneous pockets with percu-
taneous sutures within the soft triangle and the alar base. The
graft is sutured to the underlying lining.
The skin flap is elevated from distal to proximal with
2–3 mm of fat.
The dissection is deepened superiorly, protecting the flap’s
base which is dissected in the subcutaneous fat more broadly
than the proximal skin pedicle. Restricting subcutaneous
fibrous bands are released. Undermining continues until the
flap can be comfortably transferred to the defect. The cheek is
advanced and the donor site closed in layers, after excision of
the distal dog-ear. The flap is inset with a single layer of skin
sutures. The exposed raw pedicle is covered with antibiotic
ointment.
Stage 2
Three weeks later, the pedicle is divided. Skin is re-elevated
with 2–3 mm of fat over the lateral aspect of the alar inset.
Underlying subcutaneous fat and scar are excised, sculpting
a convex alar contour and a defined alar crease. The flap is
re-approximated to the recipient site. The superior aspect of
nasolabial cheek scar is re-opened, excess skin and soft tissue
is excised, and the cheek is closed.
Practically speaking, the nasolabial flap has a limited role
in nasal reconstruction. Because of the limited excess available
in the medial cheek, there is only enough nasolabial tissue to
resurface a defect of about 2 cm in width. Although a reliable
flap, excessive undermining or tension may lead to necrosis.
It will not reliably revascularize a skin graft for lining or
maintain its blood supply if folded for cover and lining. Its
arc of rotation and reach are limited. It can be transposed to
the ala, columella, or to resurface the upper lip but it will not
safely reach the tip or dorsum. Although a nasolabial flap scar
may be hidden in the nasolabial fold, the cheek becomes flat-
tened and may necessitate a contralateral excision of medial
cheek tissue to improve symmetry with the opposite cheek. A
nasolabial flap routinely transfers beard in the male.
The two-stage nasolabial flap is best employed to resurface
the entire ala, as a subunit, or an alar defect which extends a
few millimeters above the alar crease onto the nasal sidewall.
Although the alar crease will be obliterated if the defect
extends into the sidewall, a secondary operation can be per-
formed to restore the alar crease. It can also resurface the colu-
mella or a non-nasal defect of the lip or the platform for the
nasal base.
The forehead flap
The forehead with its superior color, texture, size, reach,
vascularity, lining applications, and forgiving donor site make
it the first choice for most nasal repairs. It is multi-laminar,
composed of skin, subcutaneous fat, frontalis muscle, and a
thin underlying areolar layer which separates it from frontal
periosteum. Although forehead skin matches the nose in color,
texture, and thickness, a forehead flap is thicker than nasal
nasolabial extension, which travels with a cheek flap to
resurface the primary defect. The vascularity of the
random extension is good, but can be impaired by
tension.
4. Excess subcutaneous fat is excised to match the
thickness of the flap to the depth of the recipient bed.
Absorbable sutures can be placed to gently fix the deep
surface of the flap to the underlying soft tissues at the
ideal alar crease if vascularity is maintained. If
necessary, the crease can be re-created secondarily. The
distal flap is gently laid over the inferior aspect of the
nasal wound and trimmed to fit. The incisions are
closed in layers.
Final scars blend within the sidewall or lie in the nasolabial
fold. Pin cushioning of this non-subunit skin replacement can
occur, but is minimized if the ala is supported and braced by
primary cartilage grafts to control nostril margin shape and
position.
The one stage nasolabial flap is useful for defects of the
sidewall and ala, which are not effectively repaired with other
local flaps.
It can also be used to resurface the upper lip and nasal sill
in a composite defect of the nose, lip, and cheek.40–42 Often
combined with the Millard fat flip flap,15,16 which hinges over
excess subcutaneous fat, from the lateral cheek, to restore
missing premaxillary soft tissue bulk.
Large, deep, and adversely located defects
The superiorly based two-stage subunit nasolabial flap
(Figs. 6.6, 6.7, 6.8
)
The two-stage nasolabial flap22,43 transfers excess skin from the
medial cheek, just lateral to the nasolabial fold, supplied by
blood vessels which originate from the underlying facial and
angular arteries, passing through the underlying subcutane-
ous tissue, above and below the levator labii muscle. Although
the narrow skin pedicle contributes a modest random blood
supply, the flap is a subcutaneously based island flap. If the
underlying subcutaneous vascular base is intact, the flap is
reliable even if skin lateral to the ala is scarred or has been
excised. The subcutaneous pedicle permits easy transposition
and the narrow skin component eliminates the superior
dog-ear and its scar from extending onto the nasal sidewall
on wound closure. The flap is designed with its medial border
exactly along the nasolabial fold to place the final scar exactly
in the nasolabial crease. In young patients or those with a
poorly defined fold, the nasolabial crease may be indistinct
and should be marked with ink preoperatively, before seda-
tion or general anesthesia.
Figs. 6.7 and 6.8 appear online only.
A two-stage nasolabial flap is best employed to resurface
the convex ala as a subunit. Residual skin within the alar
subunit is excised so that the entire subunit is resurfaced,
rather than just patched.
Stage I
The nasal subunits and nasolabial fold are marked with ink.
An exact template is designed, based on the contralateral ala.
The template is positioned adjacent to the nasolabial crease at
the level of the oral commissure to ensure an adequate arc of
rotation. The superior pedicle is tapered to a point lying just

138.e1
The repair of nasal defects – treatment options
A
B
C
Fig. 6.7  (A–E) Subunit reconstruction of left ala with
two-stage nasolabial flap. The subunits of the nose are
marked with ink. A template of the right contralateral alar
subunit will define the dimension and outline of the nasal
labial flap and the primary cartilage graft. Residual skin
within the left alar subunit is excised. A primary ear
cartilage graft is fixed to support the alar lining. A subunit
superiorly based axial nasolabial flap was elevated to
resurface the alar subunit.
D
E