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

139
The repair of nasal defects – treatment options
Zygomaticus major
Zygomaticus
minor
Levator labii superioris
Levator anguli oris
Facial artery
Levator labii superioris alaeque nasi
Orbicularis oculi
Orbicularis oris
A
Tapered skin pedicle
Dog-ear
excised
B
C
Fig. 6.6  (A–D) A two-stage nasolabial flap is employed to resurface the ala as a subunit. Residual normal
skin is excised adjacent to the defect and the entire subunit is resurfaced as a subunit at the first stage. The
superiorly based two-stage nasolabial flap is perfused by axial vessels which pass through the underlying
facial musculature to vascularize the proximal flap base. Primary cartilage must be placed to support and
brace the nostril margin. One month later, the proximal pedicle was divided, the alar inset completed after
soft tissue sculpturing, and the cheek donor site closed to position the donor scar exactly in the nasal labial
fold.
Continued

140
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
The two-stage forehead flap (Figs. 6.9 & 6.10
)
Anatomically, the supratrochlear vessels pass over the orbital
rim, external to the periosteum, sandwiched between the
corrugator and frontalis muscles. The vessels then travel verti-
cally upward into the frontalis muscle. At the mid forehead
level, they pass through the muscle and lie in a superficial,
subdermal position at the hairline.
Figs. 6.9 and 6.10 appear online only.
The flap can be transferred as an island flap44 in one stage,
but excessive bulk of the pedicle, passing under tight glabellar
skin, may jeopardize its blood supply or distort the nasal root.
Most importantly, the aesthetic nasal result can rarely be
obtained in a single stage.
Traditionally, a forehead flap is transferred in two stages.22
At the first stage, the flap is elevated over the periosteum.
Frontalis muscle and subcutaneous fat are excised over the
distal 1–2 cm. The distally thinned flap is transferred to the
recipient site, perfused proximally through its thick proximal
pedicle. During the second stage, 3 or 4 weeks later, when the
distal flap has become vascularized by the recipient site, the
pedicle is divided. The superior aspect is re-elevated, deb-
ulked, and the skin inset is completed.
Unfortunately, excision of muscle and subcutaneous fat, at
the time of the initial transfer, removes its myocutaneous
blood supply and may diminish vascularity. Although rela-
tively safe, flap necrosis may occur in smokers, if the flap is
under tension, or in patients undergoing major nasal repairs
which require large flaps and wide initial soft tissue thinning
or flaps with multiple narrow extensions for the ala or colu-
mella. Most importantly, although tip and alar cartilage
support may be placed at the first stage, the skin of the distal
nose – the tip and ala – is not re-elevated during pedicle
division. Any imperfection in the most aesthetic part of the
nose cannot be altered prior to pedicle division.
skin. Excess frontalis and subcutaneous fat must be removed
to thin the flap to blend into the adjacent facial skin.
The forehead is perfused from the supraorbital, supratroch-
lear, the superficial temporal and posterior auricular arteries.
Flaps can be based on each of these pedicles – the median
forehead flap, the horizontal forehead flap, the up and down
flap, or the scalping flap.
Today, the paramedian forehead flap is most often used. It
transfers central forehead tissue on a unilateral vertical axial
blood supply, based on the supratrochlear vessels. Its point of
rotation is centered inferiorly towards the medial canthus.
The anatomic studies of McCarthy13 and Reece14 demonstrate
that the paramedian forehead is perfused by an anastomotic
arcade from the supratrochlear, supraorbital, infraorbital,
dorsal nasal, and angular branches of the facial artery.
The paramedian flap is the first choice for nasal resurfacing
because of its vascularity, size, reach, reliability, and relatively
minimal morbidity.22,25,45,46 It takes skin from high on the fore-
head, under the hairline, with a narrow inferior pedicle base,
within or inferior to the medial eyebrow. The inferior aspect
of the donor site can be closed primarily. If a gap remains
superiorly, it is allowed to heal secondarily. Wound contrac-
tion and re-epithelialization close any superior residual defect.
Eyebrow distortion does not occur because the gap is away
from the mobile brow. Medialization of the eyebrow is not
significant because the proximal pedicle is narrow.
A paramedian forehead flap can resurface any nasal defect
without significant donor deformity. Its pedicle is based on
either the right or left supratrochlear vessels. A central nasal
defect can be resurfaced on either pedicle, but a unilateral
nasal defect is resurfaced with the ipsilateral pedicle to
decrease the distance between its pivot point and the defect,
unless precluded by an old scar within its territory. If the
hairline is extremely low or the forehead scarred, pre-
expansion is employed, but is not routine.47–50
D
Remnant of alar subunit excised
Tail of pedicle
thinned, trimmed,
and inset
Undermined area
Fig. 6.6, cont’d

140.e1
The repair of nasal defects – treatment options
A
B
C
Fig. 6.9  (A–E) Two-stage paramedian forehead flap resurfacing of the ala as a subunit. After Mohs excision of a basal cell carcinoma, greater than 50% of the left alar skin
is missing. The nasal subunits are marked with ink. Excess skin within the alar subunit is discarded. The lining is supported with a primary ear cartilage graft. A right
paramedian forehead flap is designed vertically over the supratrochlear vessels. It is thinned distally and transferred to the defect.
D
E

140.e2
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CHAPTER 6 • Aesthetic nasal reconstruction
A
B
C
Fig. 6.10  (A–F) One month later,
the forehead pedicle was divided.
Skin within the superior aspect of the
recipient site is elevated thinly and
underlying cutaneous fat and primary
cartilage graft is excised to sculpt a
convex ala and deep alar crease.
Excess skin history and in the inset is
completed with quilting sutures in a
single layer of fine peripheral sutures.
No revision.
D
E
F

141
The repair of nasal defects – treatment options
traditional two-stage forehead flap to improve vascular safety
and permit more aggressive soft tissue contouring They
thinned the flap distally at transfer but, 3 weeks later, elevated
it from its bed over the mid-nose. The proximal pedicle
remained intact while the distal inset was left attached over
the tip, alar margins, and columella. Underlying fat and
muscle over the dorsum and midvault were excised to
improve midvault contour.
Although helpful, visualization of the middorsal excision
was obstructed by the proximal pedicle and distal inset. Most
importantly, once the flap was applied to the ala and tip at the
first stage, further soft tissue sculpting or cartilage modifica-
tion of the distal nose could not be performed.
Menick,25,71 in the late 1990s, modified the approach by
transferring a full-thickness flap in three stages. The forehead is
multi-laminar and consists of skin, subcutaneous fat, and
frontalis muscle. It is perfused with a myofascial, axial, and
random blood supply. Initial distal thinning removes the
myocutaneous component and creates a wounded soft dermal
surface, more prone to contraction and less able to tolerate
tension. However, if the flap is transferred with all its layers,
maximal vascularity is maintained and the expected indura-
tion of wound healing does not occur, even months after
transfer, as long as its subcutaneous plane is not injured or the
frontalis excised. One month after transfer, the full-thickness
flap’s blood supply is augmented by surgical delay (its initial
peripheral incision, elevation, and transfer). Forehead skin,
with 2–3 mm of subcutaneous fat, can be completely elevated
off the entire nasal inset, maintaining the proximal pedicle.
The underlying excess of subcutaneous forehead fat and
frontalis, previously positioned cartilage grafts and lining are
rigidly healed together. With complete visualization, the soft
tissues are excised and cartilage grafts sculpted, repositioned,
or augmented to refine 3D contour. The thin supple forehead
skin is then replaced to resurface the nose. Pedicle division is
performed one month later.
Although this three-stage approach with a full-thickness
flap adds an additional operation prior to pedicle division, it
ensures a maximum blood supply at each stage, a thin uniform
covering skin flap, unimpeded surgical exposure, controlled
soft tissue shaping, and cartilage grafting over the entire nasal
surface prior to pedicle division. The surgeon can make
intraoperative modifications during each stage and can
perform a “revision” before the pedicle is divided. The aes-
thetic results are improved and the need for late formal revi-
sion minimized.
The three-stage full-thickness forehead flap technique, with
an intermediate operation, is applied to resurface partial-
thickness or full-thickness nasal defects, regardless of defect
size or depth. It is especially useful in smokers, when a scar
Although the two-stage forehead flap is routinely applied
to heminasal and total nasal defects, aggressive operative
debulking is required during both surgical stages. This puts
the flap in some jeopardy, leading to occasional flap necrosis,
especially in smokers. The two-stage forehead flap may be
best limited to small defects of the tip, dorsum, or ala that do
not require delicate contour recreation, complex support grafts
or lining. It is especially difficult to re-establish the subtle 3D
contours of multiple subunits when the defect is large or deep,
requiring complex support and lining replacement.
Technique of the two-stage forehead flap
(Figs. 6.9 & 6.10
)
Stage I: flap transfer
The nasal subunits are marked with ink and residual normal
skin is excised within the convex tip subunit or ala (the
Subunit Principle) but not within the flat dorsum or sidewall.
Primary cartilage grafts are positioned, as necessary, over
vascularized lining. An exact pattern of the defect, based on
the contralateral normal, is outlined under the hairline,
directly over the supratrochlear artery, which lies just laterally
to the frown crease. It can be identified by Doppler. The
proximal pedicle is drawn inferiorly, in continuity with the
defect, through the medial brow. Pedicle width at the brow is
about 1.2–1.5 cm. The reach of the flap is verified using a
simple gauze measure, checking the distance from the pivot
point below the eyebrow to the distal end of the flap on the
forehead and most inferior aspect of the defect. The flap can
be lengthened by extending the design into the hairline or,
more often, the pedicle is extended inferiorly across the
eyebrow towards the medial canthus.
Figs. 6.9 and 6.10 appear online only.
Frontalis muscle and excess subcutaneous fat are excised
within its distal 1.5–2 cm. The skin flap with 2–3 mm of fat
distally will be applied to the inferior aspect of the nasal
defect. The dissection then passes under the frontalis and over
the periosteum, through the medial brow until the flap reaches
the defect without tension. It is sutured to the recipient site,
from distal to proximal, with a single layer of fine suture. If
the flap blanches, stop suturing and let the unsutured lateral
flap edges heal secondarily to the recipient site. To avoid
excessive oozing and crusting, the raw surface of the pedicle
can be skin grafted. The forehead is widely undermined into
both temples and closed in layers. The scalp dog-ear is excised
superiorly. Any gap, which remains under the hairline, is
dressed with petrolatum gauze for one week and allowed to
heal secondarily. The scar can be revised later, if needed.
Stage II
Three to 4 weeks later, the pedicle is divided, the proximal
aspect of the flap is re-elevated with 2–3 mm of fat, and the
underlying excess soft tissue (fat, frontalis, and scar), which
is adherent to recipient site, is excised, contouring the superior
aspect of the defect. The flap remains well vascularized
through its distal inset. The superior inset is completed. The
proximal pedicle is untubed and returned to the medial brow
as a small inverted “V”, discarding any excess (Box 6.2).
The three stage full-thickness forehead flap (Fig. 6.11)
Millard, in the 1970s,29 and Burget,26 in the 1990s, added an
intermediate operation between transfer and division of the
BOX 6.2  The two-stage forehead flap is ideally suited for small
defects:
• limited to one or two contiguous subunits
• requires modest cartilage replacement
• intact lining
• low ischemic risk-the nonsmoker, no prior forehead scarring,
limited complex distal flap extensions

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SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
pedicle, with a 1.2–1.5 cm base, is marked inferiorly through
the medial brow. Primary cartilage grafts are placed if vascu-
larized intranasal lining is present or has been restored with
intranasal flaps, hingeover flaps, a second flap, or a free flap.
If the folded forehead flap or skin graft lining techniques are
planned to line a full-thickness defect, primary cartilage grafts
are precluded during the first stage but can be positioned in
a delayed primary fashion during intermediate operation.
The flap is elevated, with all its layers, above the perios-
teum. The pedicle is incised through the medial eyebrow
towards the medial canthus until the distal flap reaches the
defect without tension. Routinely, no frontalis or subcutane-
ous fat is excised. Frontalis can be trimmed along the nostril
margin or distal ala to ease inset if the flap is unusually stiff.
The flap is sutured to the recipient site in one layer. The
lies within the territory of the flap, or in large nasal defects
that require wide thinning of the covering flap, especially
with alar and columellar extensions. However, the two-stage
flap remains useful for small and superficial defects, such as
an isolated alar or tip repair.
Technique of a three-stage full-thickness forehead flap
(Figs. 6.12–6.18)
Stage I
The regional units, old scars, and the location of planned
vascular pedicles are marked with ink. Residual normal tissue
within subunits is excised, when appropriate. An exact tem-
plate of the nasal surface defect is positioned at the frontal
hairline over the supratrochlear pedicle. The more proximal
A
Fig. 6.11  (A–B) The three-stage paramedian full-thickness forehead flap. The forehead flap is elevated without distal thinning. It resurfaces a complex nasal defect with
skin, subcutaneous tissue, and frontalis muscle. During the intermediate operation, one month later, the flap is re-elevated completely from the recipient site with 2–3 mm
of subcutaneous fat. The excess underlying subcutaneous fat and frontalis muscle is excised to establish the correct 3D contour. Cartilage grafts can be modified by
sculpture, repositioning, or augmentation. The skin flap was then returned to the donor site. One month later (2 months after pedicle transfer), the pedicle is divided.
B

143
The repair of nasal defects – treatment options
elevated with 2–3 mm of subcutaneous fat (nasal thinness)
over the entire nasal inset. Axial subcutaneous vessels, lying
in the subdermal superficial fat, are left adherent to the skin
flap and are avoided. The flap is completely re-elevated and
placed to the side of the face, maintaining the supratrochlear
pedicle.
The underlying excess of subcutaneous fat and frontalis
muscle, which remains adherent to the underlying support
framework and lining, is now healed together and is a living,
rigid structure that bleeds readily. With complete exposure,
the entire exposed nasal subsurface is sculpted into a 3D
shape, highlighting the dorsal lines, alar crease, and tip con-
tours. Previously placed primary cartilage grafts can be
remodeled by sculpting, repositioning, or augmentation.
Delayed primary cartilage grafts are placed over lining
restored by the folded flap or skin graft techniques. The
forehead skin flap is replaced on the recipient bed and fixed
with quilting sutures to close the dead space and better
conform to the underlying contour.
Although the forehead flap is routinely elevated over the
entire inset, it can be left adherent to the columella and nostril
margin to maintain a bipedicle blood supply, temporarily
hanging from both the brow and the distal inset. This is useful
in a heavy smoker, when an old scar lies within the flap’s
territory; when the flap contains unusually complex exten-
sions; if the defect extends from the columella to high on the
radix requiring debulking over an extremely large surface
area; or if there is any concern for vascularity at initial transfer.
This is rarely necessary. On very rare occasions, it may be
helpful to perform two intermediate operations. The flap is
re-elevated distally, maintaining the proximal inset into the
nasal bridge, to supplement vascularity while the tip and
columella are sculpted or delayed primary cartilage grafts
placed. In a second intermediate operation, the flap is
re-elevated over the mid-bridge and the nasal root, as a
bipedicle, while maintaining the columella and rim inset. This
approach is useful if there is significant scarring within the
proximal flap and the surgeon has a concern for vascularity.
The number of stages is unimportant if the final result is good
and complications are avoided.
A
Fig. 6.12  (A) A new Mohs defect of the nasal tip lies within a nose previously
reconstructed with skin grafts and a left composite flap for cover and lining. The left
rim is retracted.
Fig. 6.13  (CD) The subunits of the nose are
marked. A subunit excision of the tip and both
ala, but not of the dorsum is performed. Skin of
the old composite skin graft is hinged over for a
left nasal rim lining. Primary cartilage grafts of
ear cartilage are placed to support, brace, and
shape the lining and future cover.
C
D
forehead donor site is closed after wide undermining. A
superior gap, which cannot be approximated, is allowed to
heal secondarily.
Stage II: The intermediate operation
Four weeks later, the forehead flap, now healed to the recipi-
ent bed, is physiologically delayed. The forehead skin is

143.e1
The repair of nasal defects – treatment options
B
(B) A new Mohs defect of the nasal tip lies within a nose previously
reconstructed with skin grafts and a left composite flap for cover and lining. The left
rim is retracted.
Fig. 6.12
A
B
(AB) The subunits of
the nose are marked. A subunit
excision of the tip and both ala,
but not of the dorsum, is
performed. Skin of the old
composite skin graft is hinged
over for a left nasal rim lining.
Primary cartilage grafts of ear
cartilage are placed to support,
brace, and shape the lining and
future cover.
Fig. 6.13

144
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
Primary closure of the forehead
The forehead is a forgiving donor site – expansive, highly
vascular, self-healing, and lending itself to secondary revi-
sion. Preliminary surgical delay or expansion is usually
unnecessary.
The paramedian forehead flap, based on the supratrochlear
vessels, harvests skin under the hairline. Its narrow 1.2–1.5-cm
pedicle width allows primary closure of the inferior forehead,
leaving a single line scar above the brow. The eyebrow is not
distorted or medialized on return of the proximal pedicle
base to the eyebrow. The forehead is closed under moder-
ate tension using several key tacking sutures and a layered
closure. The superior dog-ear is excised. If a gap remains
superiorly, it is allowed to heal secondarily. A petrolatum
bandage is applied to the raw periosteum and fixed tem-
porarily with suture for one week. The open area heals by
epithelialization and secondary contraction. The adjacent
normal forehead stretches by autoexpansion. Frequently, at
the time of pedicle division or during a revision, the area of
secondary healing can be excised and the adjacent forehead
re-advanced. Occasionally, if the defect extends high onto
the radix or extends laterally towards each medial canthus,
the inferior forehead donor cannot be closed at the time of
initial flap transfer. It is left open or temporarily skin grafted.
At pedicle division, the unused proximal pedicle is returned
to the donor site, restoring the medial brow and resurfac-
ing the inferior forehead defect. Any defect above it heals
secondarily.
Stage III: Pedicle division
Four weeks later (8 weeks after initial flap transfer), the
pedicle is divided, the nasal inset completed, and the proximal
pedicle returned to the brow as in the two-stage technique
(Figs. 6.19–6.22, Box 6.3).
Handling the forehead donor site
Foreheads vary in height and width, laxity, the presence of
scars, prior injury, or past forehead flap harvest.
BOX 6.3  Indications for a full-thickness three-stage forehead flap
• large or deep defect requiring extensive flap thinning or contour
recreation
• full-thickness defect
• significant scarring within the flap territory
• heavy smoker
B
Fig. 6.14  (B) A full-thickness paramedian forehead flap is elevated under the
frontalis. The forehead flap contains skin, subcutaneous fat, and all its frontalis
layers. It is transferred to resurface the nose without thinning.
Fig. 6.15  (AC) One month later, forehead skin with
2–3 mm of subcutaneous fat is elevated completely to
expose the entire reconstruction. The flap is temporarily
placed on the forehead.
A
C

144.e1
The repair of nasal defects – treatment options
A
C
D
(ACD) A full-thickness paramedian forehead flap is
elevated under the frontalis. The forehead flap contains skin,
subcutaneous fat, and all its frontalis layers. It is transferred to
resurface the nose without thinning.
Fig. 6.14

144.e2
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CHAPTER 6 • Aesthetic nasal reconstruction
B
(B) One month later, forehead skin with 2–3 mm of subcutaneous fat is
elevated completely to expose the entire reconstruction. The flap is temporarily
placed on the forehead.
Fig. 6.15

145
The repair of nasal defects – treatment options
A
Fig. 6.16  (A) Remaining subcutaneous fat and frontalis are now excised to sculpt a
nasal shape. Previous primary cartilage grafts are healed to the underlying lining
and can be modified. The uniformly thin forehead flap is returned to the recipient
site. It is fixed in place with peripheral sutures and temporarily molded to the
contoured surface with percutaneous quilting sutures.
Fig. 6.17  (A–C) One month
later (2 months after forehead
flap transfer), the pedicle is
divided and the distal flap
elevated thinly to allow further
subcutaneous sculpture of the
dorsum, sidewall, and ala.
A
B
C
Scars within the forehead territory
If a scar lies within the proposed flap territory, determine its
site, direction, depth, and length.
A transverse scar puts the flap at greater risk. Old operative
reports may clarify whether the injury extended only super-
ficially, injuring only the random cutaneous blood supply,
deeper through the frontalis, or directly to the vascular
pedicle. Doppler examination of the supratrochlear vessels
may confirm the presence of the supratrochlear artery.
If a scar within the flap’s territory is short, vertical, super-
ficial, or the supratrochlear vessels are verified by Doppler, it
can be disregarded. Or the surgeon may avoid a scarred area
completely by transferring skin from the opposite side of
the forehead on the contralateral pedicle. The flap can be
surgically delayed to augment its blood supply. The flap can
be elevated as a full-thickness flap to maintain all vascular
sources. An area of adjacent unscarred skin may be available
for expansion, avoiding old scars. In rare instances, when both
supratrochlear vessels have been ablated and the inferior
forehead is severely scarred, uninjured forehead skin may be
transferred on secondary vascular pedicles – a scalping or
sickle flap.
Surgical delay of a forehead flap
Surgical delay of a forehead flap should be considered when:
■ a significant old scar lies within the proposed flap
territory
■ the pedicle’s named blood supply has been injured
■ unusually complex extensions of flap design are required
(very uncommon)
■ the patient is an end-stage smoker or has a history of
high-voltage radiation
■ a non-paramedian flap extends across one vascular
territory into the territory of another flap (e.g., sickle
flap). (Supratrochlear vessels reliably perfuse the
forehead and scalp, allowing a paramedian flap to be
designed in any size or length without delay)
■ the flap’s vascularity is in doubt and a preliminary
operation is required for other reasons (prefabrication of
lining, delay of hingeover flaps).
However, unless needed, delay should be avoided. It adds
additional stages, cost, and prolongs the overall reconstruc-
tion. It can be difficult to precisely determine the requirements
of the defect until the definitive repair. Once incised for delay,
the dimension and outline of a delayed flap cannot be altered.
Technique of surgical delay
A template is positioned under the hairline and the proposed
flap’s outline is incised to periosteum. Two to 4 mm of skin
can be left temporarily intact at the columellar and alar tips
to ensure vascularity. These skin bridges may be divided
subsequently. Because all significant contributions to forehead
blood supply arise from peripheral axial vessels, elevation is
unnecessary and decreases flap pliability due to scarring of
the flap’s deep surface. Within 3–4 weeks, vessels at the flap’s
base enlarge and overall vascularity increases.

145.e1
The repair of nasal defects – treatment options
B
C
D
(BCD) Remaining subcutaneous fat and frontalis are now excised to sculpt a nasal shape.
Previous primary cartilage grafts are healed to the underlying lining can be modified. The uniformly thin
forehead flap is returned to the recipient site. It is fixed in place with peripheral sutures and temporarily
molded to the contoured surface with percutaneous quilting sutures.
Fig. 6.16

146
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
A
Fig. 6.18  (AB) Postoperative result without revision.
The forehead defect healed secondarily.
B
Fig. 6.19  (A–C) This teenage boy’s nose is significantly distorted by congenital frontonasal dysplasia. A previous attempt to reconstruct the nose with an osmotic expander
and local flaps failed. The nose is bulky and shapeless with inadequate tip support and over projecting radix. His forehead is short.
A
B
C

147
The repair of nasal defects – treatment options
Fig. 6.20  (BDE) A preliminary operation was performed to place a forehead expander and perform an open rhinoplasty to lower the radix, narrow the nasal bones, harvest
septal cartilage for a future procedure and advance the old scars onto the nasal subunit. Two months later, the nasal tip and ala were excised as a subunit and all scars
excised over the dorsum and sidewall. Lateral skin was advanced almost to the dorsal line to modify the defect. A columellar strut with advancement of the residual medial
crura and ear cartilage alar battens supported the tip. A septal cartilage graft shaped the dorsum. A full-thickness forehead flap was transferred to resurface the defect. The
position and symmetry of the alar rims seems correct intraoperatively.
B
D
E
Fig. 6.21  (CFG) One month later, due to scar contracture, support shift, or an imperfect design, the alar rims were asymmetric. During the planned intermediate operation,
the forehead skin was elevated with 2–3 mm of subcutaneous fat. The excess underlying subcutaneous fat and frontalis were excised to sculpt an ideal nasal shape. Lining
along each rim was released, hinged inferiorly, and positioned with additional delayed primary ear cartilage grafts to reposition the nostril margins inferiorly and in
symmetry. The thin forehead flap was returned to the recipient site. The forehead flap pedicle was divided 1 month later.
C
F
G

147.e1
The repair of nasal defects – treatment options
A
C
(AC) A preliminary operation was performed
to place a forehead expander and perform an open
rhinoplasty to lower the radix, narrow the nasal bones,
harvest septal cartilage for a future procedure, and
advance the old scars onto the nasal subunit. Two
months later, the nasal tip and ala were excised as
a subunit and all scars excised over the dorsum and
sidewall. Lateral skin was advanced almost to the
dorsal line to modify the defect. A columellar strut
with advancement of the residual medial crura and
ear cartilage alar battens supported the tip. A septal
cartilage graft shaped the dorsum. A full-thickness
forehead flap was transferred to resurface the defect.
The position and symmetry of the alar rims seems
correct intraoperatively.
Fig. 6.20

147.e2
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
A
B
D
E
H
(ABDEH) One month later, due to scar
contracture, support shift, or an imperfect design, the
alar rims were asymmetric. During the planned
intermediate operation, the forehead skin was elevated
with 2–3 mm of subcutaneous fat. The excess
underlying subcutaneous fat and frontalis were excised
to sculpt an ideal nasal shape. Lining along each rim
was released, hinged inferiorly, and positioned with
additional delayed primary ear cartilage grafts to
reposition the nostril margins inferiorly and in
symmetry. The thin forehead flap was returned to the
recipient site. The forehead flap pedicle was divided 1
month later.
Fig. 6.21

148
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
radial incision within the scalp or through an old scar. After
drain placement, the expander is inserted and modestly filled
with saline after closure of the scalp incision. Some weeks
later, it is injected weekly over 6–10 weeks. Distance over the
expander’s dome is measured until the skin is adequate in
length and width to resurface the defect. If the vascularity
of the flap is in doubt due to past scars, the flap is surgically
delayed, in stages, after expansion. At the time of transfer,
a template is positioned over the expanded skin. The flap
must be elevated across the supraorbital rim, transecting the
capsule at the flap’s base, to allow transposition and suf-
ficient length. The capsule is excised. Elastic recoil occurs
immediately on flap elevation and must be prevented with a
strong nasal cartilage framework to avoid retraction and skin
contraction.
Guidelines for harvesting multiple forehead flaps
■ Check the position and length of old scars.
■ Determine the available forehead surface area and
compare it to the recipient requirement. Consider use of
the contralateral pedicle.
■ Use a full-thickness forehead flap to increase vascular
safety or delay across old scars.
■ Consider tissue expansion of the flap.
■ Consider using a non-paramedian forehead flap.
■ Expand residual forehead to ease closure of the forehead
donor.
■ If the donor site cannot be closed primarily under the
hairline, allow the gap to heal secondarily.
■ If the inferior forehead cannot be closed primarily due to
the size and location of the nasal defect, return the
unused proximal pedicle to the inferior forehead to
facilitate its closure and the appearance of the eyebrow.
Expansion of the forehead
Pre-expansion, although not routinely helpful, can enlarge the
available surface of the forehead for transfer to the nose.
Forehead expansion should be considered:
1. In an especially tight forehead with limited
available skin due to scarring or prior forehead
flap harvest. Expansion can increase the length and
width of available skin within the proposed flap.
2. In the occasional, especially short forehead (less than
3–4 cm in height) to increase flap length and minimize
hair transfer to the nose.
3. To expand the donor forehead adjacent to the proposed
flap to facilitate closure of the forehead defect after
transfer of a non-expanded forehead flap.
However, there are disadvantages to expansion – delay in
repair, increased number of operative stages, added expense,
more office visits, risk of infection, and extrusion and recoil.
Expanded skin, if not rigidly braced with a hard tissue support
framework, contracts, leading to retraction and nasal shorten-
ing. Expansion does not clinically improve flap blood supply.
Expansion and delay
If scars are present within expanded skin after complete
filling, the outline of the proposed forehead flap can be drawn
over the dome of the filled expander. Its borders are incised
through the skin and subcutaneous tissue to the underlying
expander capsule to delay the flap. Subsequently, the flap is
transposed and the expander removed.
Technique of forehead expansion
The site for expander placement is outlined in the pedicle’s
territory. A sub-frontalis pocket is created through a distant
A
Fig. 6.22  (AB) A normal nose has been restored with
symmetrical nostril margins, 10 days after further
refinement of the alar creases.
B

149
The repair of nasal defects – treatment options
■ In extreme cases, when the forehead has been extensively
destroyed by previous injury or multiple flap harvest,
excise scar and residual skin within the forehead and
resurface the entire unit with a one-piece, expanded,
full-thickness, supraclavicular skin graft.
Restoring nasal contour and support:
recreating a subsurface architecture
The 3D contour and landmark outline define a nose as
“normal”. Incorrect dimension, outline, position, projection,
or symmetry describe the “abnormal”. Most of these abnor-
malities reflect a poorly sized, misshapen, or malpositioned
skeleton (Fig. 6.23).
The middle plane of the nose, between cover and lining, is
composed of two layers. Superficially lies a 3D soft tissue
layer of variable thickness composed of fat, nasalis muscle,
fibrous ligaments, and areolar tissue. More deeply lies a rigid
cartilage and bone framework which includes the nasal bones,
upper lateral cartilages, alar cartilages, the columellar and
septal partition, and the compact stiff fibrofatty tissue of the
ala. External skin and internal lining impart only minimal
stiffness and form to the nose. Bone, cartilage, and the compact
fibrofatty soft tissue of the ala determine nasal contour.
It must be remembered that the nose sits on the lip and
cheek platform of bone and soft tissue. The reconstructed nose
must be positioned and projected in symmetry and propor-
tion to other facial features. So if missing, the facial platform
must be restored and the nose built on a stable base, prior to
formal nasal reconstruction.
Hard tissue support replacement
If missing, weakened, or distorted, the middle layer of soft
and hard tissue must be restored. A complete cartilage and
bone framework must extend from the nasal bone, above, to
the base of the columella, inferiorly, and from one alar base
and sidewall to the other, horizontally. Although the ala
normally contains only soft tissue, cartilage support must be
added to prevent collapse and retraction. Cartilage grafts
support the nose and its airway, shape its external appear-
ance, and brace the repair against gravity, tension, and wound
contraction. Unlike the normal, the injured nose is subject to
edema, hematoma, tension, and fibrosis and is negatively
influenced by unnaturally thick and stiff cover and lining
replacements. The framework of the reconstructed nose must
be stronger than that of a normal nose.22,25,51–55
Timing
Ideally, if the underlying bone or cartilage structure is missing,
primary and delayed primary support grafts are placed
during flap transfer, the intermediate operation, or at the time
of pedicle division. Although, traditionally, support has been
replaced secondarily during late revisions, it is difficult to
mold cover and lining once contracted by scar.
Design
Each support graft is designed in the shape and dimension of
the subunit which it will replace. A template of the contra-
lateral normal or ideal is used to determine the appropriate
length, width, and border outline of the cartilage grafts. The
grafts are fashioned a few millimeters smaller in all dimen-
sions so when seen through thin, supple cover, they re-establish
the 3D contour of the overlying subunit.
When a non-subunit defect is resurfaced, only partial
subunit cartilage replacement is necessary (Box 6.4).
Materials
The tissue chosen to restore nasal support is of lesser impor-
tance than their shape. But materials must have the correct
dimension, bulk, outline, contour, and rigidity to satisfy the
needs of the defect.
Fig. 6.23  Subunit support. Both cover and lining of the nasal reconstruction must
be supported, shaped, and braced against wound contracture, tension, and gravity.
The middle architectural layer of the nose must be replaced. Although there is no
cartilage within the ala, the nostril margin must be supported during repair. If
missing, dorsal, tip, ala, columella, and sidewall grafts of bone or cartilage are
designed in the shape and dimension of the normal. When placed under thin
supple external skin, they will visually recreate normal surface contour while
supporting and maintaining nostril position, shape, and the airway.
Sidewall
Sidewall
Dorsal
Alar batten
Alar batten
Tip
Columellar strut
BOX 6.4  Functions of a hard tissue framework
• support cover and lining to create projection and prevent
collapse
• shape soft tissue
• brace soft tissue to prevent retraction or contracture

150
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
and helps contour the external skin. Compact soft tissue is the
primary support for the ala and soft triangle, which normally
contains no hard tissue.
Staged thinning of a full-thickness forehead flap, soft tissue
sculpturing during the intermediate operation, and contour-
ing of the proximal inset at pedicle division contribute signifi-
cantly to 3D contour.25
Restoring nasal lining
It is easy to unappreciate the importance of lining. Nearly as
much skin is required to line a nose as is needed to cover its
outer surface. Any raw area heals secondarily, distorting
the external nasal shape and airway scar contraction
(Fig. 6.24).
Alloplasts are avoided in reconstructive rhinoplasty to
avoid infection and extrusion.
The septum can supply a modest amount (2–3 × 2–3 cm) of
thin (2–3 mm), flat, moderately rigid cartilage. It is harvested
through a Killian incision or through a dorsal approach, as in
an open rhinoplasty. Septal cartilage is especially useful as a
single or layered onlay dorsal graft, a tip graft, a sidewall
brace, or a columellar strut and can be bent and fixed with
sutures to shape anatomic tip grafts or alar batten grafts.
Ear cartilage remains the work course of tip repair. The
entire concha can be harvested with little deformity through
an anterior or posterior approach. In most instances, the entire
concha is removed and the ideal graft is designed with the
precise dimension and contour needed to supply the defect,
based on a template. Like septal and rib cartilage, ear cartilage
can be shaped with horizontal mattress sutures to increase or
decrease its convexity. Its cuplike shape can be incorporated
into the curve of the alar batten graft or anatomic tip graft. It
is more difficult to create a straight columellar, dorsal, or
sidewall onlay graft from the ear.
Traditionally, rib cartilage is harvested from the synchondro-
sis of the sixth, seventh, and eighth ribs, employing Gibson’s
principles of balanced carving. However, the floating ninth
and tenth ribs are excellent donor sites due to their intrinsic
length, width, and curvature. The rib is available for a tip
graft, columellar strut, a dorsal graft, or alar batten. Osteocar-
tilaginous grafts are especially useful for dorsal replacement.
If the dorsal rib graft is 50% bone and 50% cartilage, the risk
of late warping is minimized. Unfortunately, the rib donor site
is more painful than other options.
Harvest
Based on a subunit template, the graft is examined to deter-
mine the ideal area which would best provide the appropriate
contour and dimension. Then the exact graft is cut from the
harvested material. Leftover graft is replaced in the donor site
or banked within a soft tissue pocket under scalp or chest
skin.
Graft fixation
Primary and delayed primary grafts are positioned precisely
and fixed with sutures to the residual normal skeleton, to
each other, and to the underlying lining. Late secondary
cartilage grafts can be placed in closed subcutaneous pockets,
or after elevation of the flap through peripheral or direct
incisions.
It is important to differentiate onlay grafts from cantilever
dorsal grafts. If central support remains, an onlay graft in the
shape and thickness needed to replace dorsal height is laid
over the remaining solid base. If the septum is missing or
collapsed, a rigid dorsal graft must be fixed, as a cantilever,
with a screw or plate to the radix to support the dorsal profile.
If residual septum remains within the pyriform aperture, it
may be rotated out of the nose as a septal composite flap,
based on its septal vessels, to provide central nasal support.
An onlay dorsal graft is added to shape the dorsal subunit.
Soft tissue support and contouring
Normal subcutaneous soft tissue adds shape and a degree of
strength to all areas of the nose. It pads the underlying support
A
Skin
Skin defect
Sub unit
excision ala
Full thickness
defect
Location of
cartilage graft
Fat
Cartilage graft
Frontalis muscle
Skin graft
Periosteum
Frontal bone
Fig. 6.24  (A–C) Traditional nasal lining options – the prelaminated, hingeover, and
nasolabial flaps for lining.

151
The repair of nasal defects – treatment options
lage loss within the soft triangle and nostril margin or isolated
defects of the floor or ala.56,57 Most often, a two- or three-
layered sandwich of skin, containing cartilage or fat, is taken
from the helical root, helical rim, or lobule. They survive, if
placed on a well vascularized recipient, are sutured with care,
and immobilized. They are most reliable if less than 1.5 cm in
size. Larger grafts have been recommended, with less predict-
able results. These larger grafts consist of large full-thickness
skin graft component of preauricular skin and a modest distal
composite extension for the full-thickness loss along the
nostril margin.
The nasal defect and ear are examined. An exact template
is created of the proper shape, size, and outline. The area
which best matches the contour of the defect is identified. The
graft is often harvested from the helical root. If significant
coagulative injury is present, the wound is allowed to granu-
late for 7–14 days.
The defect is re-created and the graft applied to the clean
wound. The repair is performed under local, local anesthesia
with sedation, or general anesthesia. The graft is harvested,
avoiding pressure injury, and sutured to the recipient site in
It is useful to systematically review all lining options
and to make a written list to ensure that no method is
overlooked.
Lining can be replaced by:
1. a composite skin graft
2. advancement of residual lining
3. prelamination of a forehead flap
4. folding of the distal forehead flap
5. a second flap (forehead, nasolabial, facial artery
myomucosal flap or any available discardable excess
local tissue)
6. hingeover lining flaps
7. intranasal lining flaps
8. skin graft for lining
9. microvascular transfer of distant tissue.
Composite skin grafts
Composite skin grafts of skin and cartilage, taken from the
ear, can replace small full-thickness defects of skin and carti-
B
C
Fig. 6.24, cont’d

152
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
one layer. The ear defect is repaired by suturing the external
skin of the helix to its medial surface or with a local preauricu-
lar or postauricular transposition flap, based on a superior or
inferior pedicle.
Initially, these grafts appear white. After more than 24–72 h,
they become progressively blue and subsequently pink as
vascularity improves. Ice cold compresses to decrease the
metabolic requirement of the graft in the first 48 h have been
recommended, although the clinical significance is questionable.
The “take”, color, and textures of composite grafts are
unpredictable. However, composite grafts are useful to repair
small defects (0.5–1.0 cm) along the nostril margin or within
soft triangle due to their simplicity and adequate results.
Their shiny atrophic appearance can match defects within the
“thin skin zone”.
Advancement of residual lining
Occasionally, a superficial defect along the nostril margin is
accompanied by a modest lining loss. If minimal, residual
vestibular lining can be freed superiorly from its overlying
attachment to the alar cartilage and pulled inferiorly, until it
reaches the level of the ideal nostril margin. An advancement
of 2–3 mm is maintained with a rigid primary cartilage graft
to prevent retraction. The external skin loss is replaced with
a vascularized cover flap.
The prelaminated forehead flap
In the prelaminated technique (formerly referred to as
prefabrication), the nose is “built on the forehead”.58–60,76
During a preliminary operation, a full-thickness skin graft is
placed on the deep areolar surface of the forehead’s frontalis
muscle to supply 1–1.5 cm of distal lining for the alar rims.
The flap is elevated only enough to position the skin graft,
which is immobilized with a small sponge bolus. A separate
cartilage graft is buried in a subcutaneous pocket, placed
through an incision along the lateral flap border between the
frontalis muscle and overlying skin to support to the future
distal nostril margin. If desired, a composite graft from the
ear or septum can be used in place of separate skin and
cartilage grafts.
Once healed 6 weeks later, the composite forehead is trans-
ferred to provide cover, lining, and support as a single unit.
Although prelamination adds a preliminary stage, the place-
ment of skin and cartilage grafts and subsequent flap transfer
and division are modest procedures and can be performed
under light monitored sedation in a sick patient. Prelamina-
tion avoids extensive intranasal manipulation.
Traditionally, prelamination has been used to repair signifi-
cant unilateral or bilateral full-thickness defects and has been
combined with hingeover flaps, based on the scar along the
border of an old full-thickness defect. The turned-over lining
replaced the superior aspect of the defect while the distal
aspect was lined with the prelaminated flap. Unfortunately,
cartilage grafts, within a prelaminated flap, do not have a
nasal shape and are fixed by the scar which forms around
them as they heal on the forehead. The limited size, shape,
and position of these cartilage strips provide only modest
support to the nostril margin. Incompletely braced skin graft
lining contracts, retracts the rim, and narrows the nostril
aperture.
Prelamination of the forehead flap to repair a full-thickness
defect has limited application but may be used for:
■ a small-to-moderate defect
■ in the elderly or debilitated patients to minimize
anesthesia and morbidity
■ in salvage cases, when other options are unavailable.
Hingeover lining flaps
When a full-thickness defect is created, whether sutured pri-
marily or allowed to heal secondarily, residual cover and
lining become contiguous along the defect margin. Six to 8
weeks later, external skin, an old skin graft previously applied
to resurface an adjacent superficial skin loss, or scar adjacent
to the healed margin can be hingeover, turning outside cover
into inside lining.15 Although the external skin deficiency is
enlarged, the additional skin required to resurface the proxi-
mal nose is easily supplied by the proximal pedicle of the
forehead flap used for cover.
Turnover flaps are vascularized across the scar at the
wound margin. Because of their relative avascularity, they are
unreliable if more than 1–1.5 cm in length. Hingeovered scar
is less likely to survive. Even a minor hingeover lining loss
may lead to infection, especially if cartilage grafts are simul-
taneously placed for support. To improve their limited vascu-
lariy, a preliminary delay, 3–4 weeks earlier, can be performed.
The hingeover flap is incised, elevated inferiorly, and then
returned to its bed. However, the usefulness of surgical delay,
in this instance, is in doubt. It adds an additional surgical
stage, delays the repair, increases fibrosis, and does not defi-
nitely improve survival.
Hingeover flaps are thick, stiff, modestly vascularized, and
noncompliant. They are less easily shaped by primary carti-
lage grafts and their bulk may distort external nasal contour.
Indications for hingeover lining flaps
■ To line small full-thickness defects after cover and lining
have heal together along the wound margin.
■ In salvage cases, all layers of the nose may be injured
with nasal collapse and retraction. This is most
commonly seen after multiple failed rhinoplasties,
following intranasal lining necrosis with cartilage
infection and collapse (as in the cocaine nose) or after
prior failed reconstructions. In these instances, few lining
options remain. Because scarred external skin will be
replaced with a flap, it can be turned over to line the
distorted distal margin, rather than being discarded.
■ In pediatric nasal reconstruction, injury to the growth
centers of the nose should be avoided until near complete
physical maturity. Hingeover flaps of residual skin, which
borders the margins of the defect, can provide lining,
while avoiding additional intranasal injury in the child.
■ Composite skin grafts are another option in the child.
The disadvantages of hingeover flaps are:
■ they are not applicable to the repair of a fresh nasal
injury and require at least 6–8 weeks to allow the
external and internal surface of the nose to heal and
establish vascular connections across the scar
■ they are thick, stiff, and less able to be molded by
cartilage grafts

153
The repair of nasal defects – treatment options
■ that if the initial defect encompassed most of the
circumference of the airway, as the scar contracts, the
airway becomes stenotic. Even though the
reconstructed nostril margin may appear large after
turning over external skin for lining, the internal
stenosis cannot be opened initially without
jeopardizing the vascular base of the hingeover flap.
Late revision to open the constriction deep within the
nose is difficult. In such cases, open up the constriction
initially, prior to the formal nasal repair. Later adjacent
external skin is turned over for lining operation.
However, this further postpones formal nasal repair.
Use of a second flap for lining
If the full-thickness defect, external skin can be replaced with
a forehead flap and lining replaced with a second flap, with
a separate blood supply.
The nasolabial flap
Millard15 popularized the use of random nasolabial flaps of
cheek skin for lining. For large defects, which included the
midvault and lower one half of the nose, he hinged over
residual skin from the upper nose to line the midvault and
rolled over skin and fat within the nasolabial fold to line the
distal aspect of the defect. For subtotal nasal defects, bilateral
nasolabial flaps were turned inward, after surgical delay, to
line each ala and one half of the nasal vault, suturing the distal
end of each nasolabial flap together centrally to supply colu-
mellar lining.
If employed to line a small defect of the lateral ala, no more
than about 1.5 cm in length, they can survive, based only on
scar about the pyriform aperture. Longer nasolabial lining
flaps should include the angular and facial artery perfora-
tors at their base. Unfortunately, these flaps are thick and
stiff and cannot be thinned at the time of transfer without
jeopardizing blood supply. Primary cartilage grafts are
often precluded by the excessive soft tissue bulk and risk of
necrosis with infection. Late revision is required to thin the
nostril rims, open the airway, and contour the nasal surface.
These flaps add scars to the central face and cannot be posi-
tioned exactly in the nasolabial fold. The technique is rarely
used today.
A second forehead flap25
It is possible to line the nose with a second forehead flap based
on the opposite supratrochlear or superficial temporal vessels.
Whatever forehead skin necessary to rebuild a nose should be
harvested. However, forehead skin is best used only for cover.
Injury to the remaining forehead skin should be avoided, if
possible, to minimize scarring and permit harvesting of a
second flap for a second nasal reconstruction needed in the
future.
The facial artery myomucosal flap (FAMM flap)
The FAMM flap61 is an axial oral musculomucosal flap based
on the facial artery which can line defects of the mouth and
nose. It consists of intraoral mucosa, submucosa, a small
amount of buccinator muscle, the deeper plexus of the orbi-
cularis oris muscle, and the facial artery and its venous plexus.
Based superiorly at the alar base and centered over the facial
artery, oral mucosa and the overlying facial artery are raised,
from distal to proximal, and passed into the nasal cavity at
the alar base. The flap is 89 cm long and 1.5–2.0 cm in width
and can line an isolated area of lining loss within the middle
vault secondary to cocaine injury or Wegener’s disease. Its
primary advantages are its vascularity and ability to provide
intranasal lining without adding visible scars to the external
face. Bilateral flaps can be used.
Intranasal lining flaps
Intranasal stratified squamous and nasal mucoperichondrium
are perfused by branches of the facial and angular arteries,
the septal branch of the superior labial artery, or the anterior
ethmoidal vessels.62–68
The lateral nose is perfused from branches of the facial and
angular artery which supply the ipsilateral alar base and
middle vault. The centrally placed septum is perfused inferi-
orly from bilateral septal branches of the superior labial
arteries, which arise from the facial artery. The superior labial
artery passes medially through the orbicularis oris muscle
along the skin vermilion junction of the upper lip. Its septal
branch arises just lateral to the philtral column and moves
vertically upward, lateral to the nasal spine, to supply the
ipsilateral septal mucoperichondrium. The septal branch is
located at the base of the columella within 1.0–1.2 cm of the
nasal spine between the anterior plane of the upper lip and
the inferior edge of it perform aperture. Each side of the septal
mucosa is perfused by its ipsilateral septal branch. The entire
septum containing septal cartilage and lined with bilateral
mucoperichondrium, is vascularized by both superior labial
vessels. The dorsal aspect of the septum is perfused by paired
anterior ethmoidal vessels which pass from under the nasal
bones to perfuse each side of the septal mucoperichondrium,
dorsally (Fig. 6.25
).
Fig. 6.25 appears online only.
Residual intranasal mucosal can be moved to line a defi-
ciency depending on the defect location and size and the
pedicle position, dimension, and reach of each individual
lining flap, as described by Burget and Menick.22,25,69,70 These
flaps may be unavailable if prior surgery or traumatic injury
has interrupted their named vessels or their mucosal
surfaces.
■ A bipedicle vestibular skin flap can be employed if
residual vestibular skin remains above a marginal defect.
It is incised superiorly in the area of the intercartilaginous
space, creating a bipedicle flap, based medially on the
septum and laterally on the nasal floor. It is perfused,
medially by the septal branch of the superior labial
artery, and laterally by the branches of the facial angular
artery. The flap is pulled inferiorly, like the hem of a skirt,
to line the nostril rim. The superior defect, created by
advancement of the bipedicle flap, is filled with an
ipsilateral septal flap, a skin graft, or with a contralateral
mucoperichondrial flap.
Ipsilateral septal mucoperichondrial flaps, based on the
right or left superior labial artery, can be elevated off
septal cartilage and transposed laterally and inferiorly to
line the vestibule and the lateral sidewall.
■ A contralateral mucoperichondrial flap, based on the
dorsum of the septum and vascularized from branches of
the ipsilateral ethmoidal vessels, can be hinged laterally
to line the contralateral midvault. As originally described

153.e1
The repair of nasal defects – treatment options
Fig. 6.25  (A–D) Blood supply and design of intranasal lining flaps.
A
Facial artery
Facial artery
Angular artery
Superior labial
artery
Septal branch of
superior labial
artery
Septal branch
Anterior ethmoid branch
Medial internal nasal branch
anterior ethmoid artery
Septal branch posterior ethmoid artery
Greater palatine artery
B
Bipedicle flap

153.e2
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
C
Slit made in
ipsilateral
mucoperichondrial
Septal cartilage to be fashioned into sidewall graft
Ipsilateral septal flap
Area of contralateral
septal flap
Contralateral
mucoperichondrial flap
Ipsilateral
mucoperichondrial
Fig. 6.25, cont’d

153.e3
The repair of nasal defects – treatment options
D
Cartilage to
be trimmed
Fixation point
Excess
lining
Pedicle
Septal branch of
superior labial
artery
Flap of mucoperichondrium
and septum
Fig. 6.25, cont’d

154
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
by deQuervain, the ipsilateral septal mucosa was
discarded, and a flap of cartilage and septal mucous
membrane was swung laterally through a large septal
fistula. It is more practical to preserve the ipsilateral
mucosa, remove the septal cartilage, preserving a septal
“L” strut, and pass the flap through a dorsal slit in the
ipsilateral septal mucosa, preserving the opposite septal
mucosa. The harvested septal cartilage is reapplied to
support the mucosal repair after transfer, facilitating its
design and positioning. This contralateral dorsal septal
flap can line the midvault, an isolated defect of the
midvault, the gap above a bipedicle vestibular flap, or
above an ipsilateral septal flap transferred to line the
inferior nose. It is inadequate in size and reach to line the
nostril margin or alar base, inferiorly.
■ A composite septal flap based on paired septal branches
of the superior labial artery lying adjacent to close to the
nasal spine. The entire septum rotated as an inferior
pedicle base out of the pyriform aperture, transposing a
“septal sandwich” of support and bilateral lining anterior
to the plane of the face to restore basic central support
and lining to both vestibules, columella, and the middle
vault and dorsum. Its mucoperichondrium lining can be
turned to line the lateral nose but is inadequate in length
to reach the alar base and must be supplemented
laterally, most often with flaps from the residual ala or
nasolabial fold.
Intranasal lining flaps may be applied to varied
defects, according to their location and dimension:
1. Isolated unilateral defect of the midvault – use contralateral
septal mucosal flap.
2. Unilateral defect of the lower one third of the nose – use
bipedicle vestibular flap and ipsilateral septal flap.
3. Unilateral defects up to one half of the nose – use bipedicle
vestibular flap and contralateral septal flap.
4. Unilateral defects of the vestibule, middle, and upper vaults
– use ipsilateral and contralateral septal flaps.
5. Central defect of the dorsum and tip – use septal
composite flap.
6. Central defect combined with lateral alar lining loss – use
septal composite and turnover alar remnant or nasolabial
flaps.
operation. Although highly vascular, they are unpredictable
in the smoker or in major repairs when multiple intranasal
flaps combined to line large defects. A minor cartilage expo-
sure may lead to serious infection and tissue loss.
They are fragile and should be elevated subperichondrially
to protect their blood supply. Their dissection is destructive
to the nose and increases the overall morbidity of nasal repair
due to temporary bleeding, crusting, and obstruction. Fortu-
nately, the surgical fistula heals spontaneously around its
border and becomes self-cleansing. Whistling does not occur
because of the fistula’s large size. Intranasal flaps are relatively
complex and time consuming. The final result may be marred
by late retraction, external distortion or narrowing of the
airway. The lack of rigidity and limited dimensions of intra-
nasal lining flaps, the relatively unstable cartilage construction
with multiple-suture fixated grafts, dead space, and scar
contracture limit the final result. Late nostril stenosis may
occur. However, intranasal lining flaps remain a valuable tool
in the repair of isolated midvault or large unilateral full-
thickness defects when other methods are less applicable.
Intranasal lining flap technique (Figs. 6.26–29 )
Isolated unilateral midvault lining loss
To repair the midvault, the contralateral septal mucoperichon-
drium is harvested through the full-thickness defect. Or if the
ala remains intact but has been malpositioned superiorly by
midvault scar or prior excision, a full-thickness incision
releases the remaining inferior nose in symmetry to the oppo-
site normal side. The ipsilateral septal mucoperichondrium is
incised transversely at the dorsum, exposing septal cartilage.
The ipsilateral mucosa is elevated. Preserving 8–10 mm of
superior dorsal support, the underlying septal cartilage is
incised transversely in line with the anterior dorsal edge and
septal cartilage is harvested for graft material. The contra-
lateral mucosa is preserved and the anterior ethmoidal vessels
are protected. A dorsally-based flap of contralateral septal
mucosa is incised, maintaining its dorsal blood supply. The
contralateral flap is then passed through the ipsilateral dorsal
slit and pulled laterally to the periphery of the midvault lining
loss. The raw surface of ipsilateral flap, which now lies
exposed with the contralateral airway, heals spontaneously.
Harvested septal cartilage and bone is fashioned into a side-
wall brace to support and shape the midvault and prevent the
ala from retracting upward postoperatively. Missing external
skin is advanced from the cheek or transposed from the
forehead to resurface the external skin loss.
Figs. 6.26 and 6.27 appear online only.
If the unilateral defect of the nostril margin is less than 1 cm
in height, residual stratified squamous skin remains above the
defect. A bipedicle flap of remnant vestibular skin, between
the edge of the defect and the internal nasal valve, is moved
caudally to line the nostril margin. The dry stratified squa-
mous epithelium of the vestibular flap is less easily trauma-
tized than septal mucosa, which can appear abnormally,
secrete mucus, and bleed, if abraded. Medially, the flap is
perfused through its connection to the ipsilateral septal lining
at the septal angle. Laterally, it is vascularized by multiple
branches of the facial angular arteries at the alar base.
A bipedicle flap, 8 mm wide, is designed within the exist-
ing lining, just above the defect. The incision of the flap’s
superior border (similar to the intercartilaginous incision of
Although significant lining can be provided by intranasal
lining flaps, they have no shape and collapse into the nose.
However, they are thin, pliable, and vascular which permits
the immediate restoration of support with primary cartilage
grafts. This combination of intranasal lining flaps and primary
cartilage grafts was a significant advance in nasal reconstruc-
tion. For the first time, reliable, thin, supple, vascularized
lining was available which would not occlude the airway or
distort the external shape. And cartilage grafts could be
positioned primarily to support, shape, and brace the soft
tissues at the initial stage.
However, the limitations of intranasal lining flaps must be
understood. Intranasal lining flaps are limited in dimension
and availability due to their modest size, limited reach, or
prior injury to their blood supply due to trauma or previous

154.e1
The repair of nasal defects – treatment options
Fig. 6.26  (AB) Reconstruction of a complex full-thickness nasal defect with a three-stage full-thickness forehead flap and intranasal lining flaps. A large, full-thickness
defect is present after skin cancer excision. Skin is missing from the dorsum tip left sidewall and medial cheek. The tip cartilages and left upper lateral cartilage are
missing. Lining for the left ala and sidewall are absent. The medial cheek defect was initially repaired with a fat flip-flap and cheek advancement to allow reconstruction on
the stable platform. This will be repaired with intranasal lining flaps and a three-stage full-thickness forehead flap.
A
B

154.e2
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
Fig. 6.27  (A–C) Six weeks later, the ipsilateral septal mucoperichondrium is elevated off the underlying septal cartilage and hinged downward and laterally on the septal
branch of the left superior labial artery. Cartilage within the exposed septum is harvested, maintaining dorsal and caudal septal support. The contralateral septum is incised,
maintaining a superior base perfused by the anterior ethmoidal arteries. The ipsilateral septal flap is fixed laterally to line the nostril margin and ala and the contralateral
septal flap is transposed to provide lining of the nasal sidewall. Because the defect included part of the right ala, additional skin within the residual right ala was discarded
to allow resurfacing of the nose as a subunit.
A
B
C

155
The repair of nasal defects – treatment options
Fig. 6.28  (A–C) Primary ear and septal cartilage grafts are placed to shape, support, and brace the reconstruction. These grafts included a columellar strut, tip graft,
bilateral alar margin grafts, and a sidewall brace. The nasal defect with resurfaced as a nasal subunit with a full-thickness forehead flap. An intermediate operation to thin the
forehead flap and sculpt the soft tissues and pedicle division were subsequently performed.
A
B
C
Fig. 6.29  (A–C) Postoperative result. No revision.
A
B
C
an aesthetic rhinoplasty) is carried through the vestibular
lining into the overlying soft tissues. The medial crus of the
alar cartilage may be divided to mobilize the flap adequately.
The flap is separated from the overlying subcutaneous tissues
and hinged medially and laterally, as a bipedicle, to the level
of the proposed nostril rim. The secondary defect, which
remains above after advancement of the bipedicle flap, is
filled with an ipsilateral septal flap. The ipsilateral septal flap,
which measures up to 3 × 3 cm in width and length, passes
towards the medial canthus about 6–8 mm below the dorsum
and then travels posteriorly with a right angle to the nasal
floor, proceeding anteriorly back towards the nasal spine. It is
incised longitudinally with straight scissors. Its distal end is
cut with a right angle scissors. A 1.2 cm soft tissue pedicle
is maintained in the vicinity of the nasal spine to maintain the
ipsilateral septal branch of the superior labial artery. The
mucoperichondrium is elevated off the cartilage and bone of
the septum and swung laterally. It is sutured to the superior

156
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
Central deep nasal defects of the inferior nose are classified
as subtotal (part of the projecting septum and bones at the
radix are preserved) or total (loss of all soft tissue structures,
anterior septum and nasal bones flush with the frontal bone
of the maxilla). Fortunately, a large part of the anterior septum
may remain projecting from the facial plane or lie hidden
within the pyriform aperture. Residual septum can be pulled
out to provide lining for the projecting parts of the nose and
its septal cartilage can be used as a foundation on which to
rest a dorsal strut. The loss of the nasal bones is especially
significant because they normally provide the fulcrum for a
cantilevered dorsal support graft. In these instances, Millard
perform a preliminary operation to reconstruct a bony base at
the radix using local hingeover lining and a bone graft,
covered initially by a median forehead flap. In other cases, he
employed a superiorly based, L-shaped, full-thickness septal
flap which was hinged out of the pyriform aperture to rees-
tablish limited dorsal and caudal septal support and lining.
Later, hinged-over flaps of local tissue and bilateral nasolabial
flaps were turned inward to line the midvault, ala, and colu-
mella. A cantilever bone graft was anchored to the preplaced
fulcrum to establish dorsal support, and a second forehead
flap was used for cover. However, such methods are unreli-
able due to vascularity, bulk, or inadequate support.
The modern septal composite flap, based on both superior
labial arteries, mobilizes the entire septum out of the nasal
cavity and projects it in front of the face. It positions a vertical
sheet of bone and cartilage to support the dorsum of the nose.
A dorsal costochondral rib graft can be placed on this hard
tissue base and fixed to the residual nasal bones, or with a
plate and screw, at the radix. The bilateral excess of septal
mucosa is hinged laterally to provide lining for the lateral
aspects of the defect.
The full-thickness of the septum is cut superiorly and
inferiorly. Distally, it is transected with a right angle scissors.
The mucosa is preserved in the region of the nasal spine and
upper lip to preserve the right and left septal branches the
superior labial arteries within a 1.2-cm soft tissue pedicle. At
the base of the flap, mucoperichondrial is separated on each
side of the cartilaginous septum to remove a small wedge of
bone and cartilage over the nasal spine. This allows the septal
composite flap be drawn out of the pyriform aperture on a
soft tissue tether. The deep aspect of the flap is anchored to
the stumps of the upper lateral cartilage or to the nasal bones
with permanent suture or wire. The intranasal donor site is
closed by mucosa to mucosa repair where possible. A large
permanent septal fistula is created.
If the defect is limited to the superficial upper or midvault,
the composite flap restores the central bony platform while
the mucosa of the right and left sides of the septum is reflected
laterally and sutured to the lateral border of the defect to
provide a complete vault lining. Primary subunit cartilage
grafts are positioned to support and shape the covering
forehead flap. In subtotal or total nasal reconstructions when
the tip and ala are also missing, it is safer to mobilize and fix
the septal composite flap to the radix or upper lateral carti-
lages. After insuring vascularity and healing to the residual
nasal root, 6–8 weeks later, the exposed dorsal mucosal edge
is split at its center and bilateral flaps are turned laterally.
Superiorly, the septal mucosa is sufficient to line the upper
and middle vaults, however. More inferiorly, it will not reach
the alar bases to line the vestibule and ala, laterally. Additional
aspect of the defect, laterally along the pyriform aperture, and
inferiorly to the bipedicle flap to create a complete lining
sleeve for a unilateral nasal defect. The size of the flap is
primarily limited by the surgeon’s ability to incise within the
confines of pyriform aperture. The flap can extend up to the
medial canthus and inferiorly to the nasal floor. Leaving a
strong septal “L”, the central septal cartilage is harvested for
graft material.
In larger defects, the secondary defect becomes too large
to be replaced with an ipsilateral septal flap whose length is
limited by the twist of its pedicle. The width of the flap may
not be adequate to fill the height of the residual defect. In
this instance, the contralateral septal flap is employed. First,
the bipedicle flap of vestibular skin and mucosa is swung
inferiorly. The ipsilateral septal mucosa is incised below the
dorsum and elevated submucosally in line with the nasal
bridge. The underlying septal cartilage is incised, protecting
the contralateral mucosa. Septal cartilage is harvested, leaving
a strong “L” strut. The dorsal mucosa is left intact while two
parallel cuts are incised and then connected along the floor
of the nose. The flap is pulled to the ipsilateral mucosal slit
to line the middle vault in the superior aspect of the vestibule
while the bipedicle flap restores the nostril margin. The flaps
are sutured to one another and supported by an alar batten
and a sidewall brace of primary cartilage graft. The dorsally
based, contralateral septal flap can be designed to extend
onto the ipsilateral nasal floor, increasing its length and
allowing it to reach across the midline to the lateral aspect
of the pyriform aperture. A wide flap can be designed along
the entire dorsum to insure adequate vertical dimension to
fill the height of the defect. However, the contralateral septal
flap does not have a length or width to reach inferiorly to the
nostril rim. It is only useful for moderate midvault lateral
nasal defects.
If the lining defect extends from the nostril margin to the
nasal bones, an ipsilateral septal mucosal flap can be used to
line the nostril margin inferiorly and a contralateral septal
mucosal flap can be swung simultaneously to line the middle
and upper vaults. This technique creates a permanent septal
fistula, which is usually well tolerated. The mucoperichon-
drium is dissected off the entire ipsilateral septal, as in an
submucous resection (SMR). The flap is swung laterally to
expose septal bone and cartilage which is harvested for graft
material, maintaining an L-shaped strut of cartilage for dorsal
and caudal support. Then a contralateral flap, based the
dorsum and anterior ethmoidal vessels, is incised, maintain-
ing its dorsal pedicle and swung laterally to line the midvault.
The ipsilateral septal flap is draped laterally towards the alar
base to line the vestibule. The contralateral septal flap is
passed through the septal fistula and sutured to the lateral
edge of the nasal defect and then to the ipsilateral flap. The
pedicle of the ipsilateral flap may partially obstruct the airway
and need to be divided subsequently to open the airway.
Central lining defects
In superficial dorsal defects, the high, converging medial, and
lateral walls of the upper and middle vaults may permit
simple side-to-side approximation of lateral sidewall mucosa
and medial septum if a modest central defect lies within the
superior nose. This may lower the height of the nasal vault
but may not significantly diminish nasal function. The height
of the nasal bridge is restored with cartilage grafts.

157
The repair of nasal defects – treatment options
No primary cartilage support is placed with the folded flap.
However, primary cartilage grafts are placed in neighboring
areas of more superficial injury over intact vascular lining.
At the second stage four weeks later, the proposed nostril
margin is marked with ink, based on templates of the contra-
lateral normal alar rim or the ideal. The nostril margin is
incised in the area of folding, separating the proximal covering
skin from its distal lining extension. The proximal aspect of the
covering flap is re-elevated with 2–3 mm of subcutaneous fat.
Because the frontalis muscle was not excised or the subcutane-
ous plane of the flap injured during transfer, cover and lining
skin remain soft, supple, and uncontracted. More importantly,
the folded distal extension, which was designed to line the
nasal repair, is now healed and integrated into the residual
normal lining. It is no longer dependent on the proximal fore-
head flap and its supratrochlear pedicle for vascularity. The
exposed double layer of soft tissue – residual subcutaneous
fat and frontalis – is excised to reveal thin, supple, and highly
vascular lining. Delayed primary grafts are placed to create a
complete alar subunit support framework. The thin, supple,
unscarred skin of the proximal flap is returned to the recipient
site (Video 6.2
). At the third stage, 4 weeks later (6–8 weeks
after beginning the nasal repair), the pedicle is divided.
This modified folded forehead flap lining technique is reli-
able, efficient, and effective in the repair of full-thickness
unilateral and bilateral defects. It is employed to repair of
lining defects up to 3.0 cm in size and is useful for all small
to moderate full-thickness defects. It avoids complex intrana-
sal manipulation and minimizes the risk of postoperative
bleeding or nasal obstruction often associated with intranasal
lining flaps. The operative time is shortened, with less intra-
nasal morbidity. If the defect extends from the ala onto the
nasal floor, an additional distal extension can be added at
right angles to the alar lining extension to line the ala and
resurface the nostril sill. The vascularity of a full-thickness
forehead flap is illustrated by the safety of such complex skin
extensions.
Although all available lining options should be considered
for any specific defect, the modified folded forehead lining
alar lining must be supplied by hingeover flaps, turned
up from a residual alar remnant or from a nasolabial flap.
Presurgical delay of these local flaps may increase their
reliability.
The modified folded forehead flap for lining
(Figs. 6.30–6.38 )
Folding the distal end of the forehead flap onto itself to supply
external cover and internal lining is a traditional method.7
Unfortunately, the traditional design made it difficult to posi-
tion cartilage or bone grafts due to the bulk of soft tissues
and limited exposure. The reconstructed nose was thick,
shapeless, and the airways were collapsed and occluded.
A modified folded approach using a forehead flap in three
stages provides an opportunity to combine primary and
delayed primary cartilage grafts and subcutaneous soft tissues
sculpture. It is an efficient method applicable to many lining
defects (Video 6.1
).
Figs. 6.31D, 6.32A,B,D, 6.33B,C, 6.34A,B, and 6.37A,D
appear online only.
As described by Menick,25,71–73 an extension of a full-
thickness paramedian forehead flap, based on an exact tem-
plate of the lining defect, is folded inward. Because the donor
site lies within the area of forehead normally discarded as a
dog-ear, there is minimal additional injury to the forehead. If
the lining template must extend to the hairline, any transferred
follicles simulate intranasal vibrissae and can be trimmed,
postoperatively.
The flap, as a single cover and lining unit, is elevated from
the distal to its proximal base, as a full-thickness flap. The
distal lining extension (which can be partially thinned if the
full-thickness flap is especially stiff and difficult to turn inward)
is folded inward and sutured to the residual mucosal lining of
the defect. The more proximal aspect of the flap is folded back
onto itself to provide nasal cover, creating a layer of external
skin, subcutaneous fat, and frontalis muscle which provides
nasal cover resting against an inner layer of frontalis muscle,
subcutaneous fat, and skin, which replaces the missing lining.
B
A
Lining template
Cover template
Subunit
excision ala
Folded lining
Fig. 6.30  (A–C) Folded forehead flap for lining-design and transfer. Based on exact patterns, a full-thickness forehead flap is elevated without thinning to supply external
skin cover with the distal extension which will be folded inward to replace missing nasal lining. No primary cartilage grafts are placed.
C

158
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
Fig. 6.31  (ABC) The intermediate operation of the modified folded forehead flap. One month later, the folded forehead flap lining extension is healed to the adjacent normal
nasal lining and is no longer dependent on the forehead flap for its supratrochlear blood supply. The regional units of the nose an ideal alar margin are marked with ink. The
forehead flap is incised between covering lining along the nostril margin and the covering flap was elevated with 2–3 mm of subcutaneous fat. This exposes the underlying
unsupported subcutaneous fat and frontalis muscle which is excised from the underlying lining of folded forehead skin. A delayed primary cartilage graft is positioned to
support the ala (and sidewall, if needed). The thin forehead flap is returned to the recipient site for nasal cover. One month later (2 months after the initial flap transfer), the
proximal pedicle is divided.
A
B
Frontalis folded
C
Delayed primary
cartilage graft
Fig. 6.32  (C) A full-thickness defect of the right ala and sidewall is present after
Mohs excision. The regional units of the nose and the ideal alar base position are
marked with ink based on the template of the contralateral normal upper lip.
Templates were designed to replace the missing cover and lining exactly in
dimension and border outline. A full-thickness forehead flap is elevated with the
distal extension for lining and folded to replace missing nasal lining and the more
proximal distal flap is turned back to resurface the defect. No primary cartilage
grafts were placed. The raw pedicle of the forehead flap was skin grafted for
cleanliness.
C
technique should be a workhorse in nasal reconstruction. Due
to its vascularity, it is safe in the smoker. Due to the shortened
operative time and limited and intranasal manipulation, it is
useful in the elderly or those with unassociated medical
illness. When re-opening a healed defect, the surgeon can
define the defect and immediately provide vascularized lining
to fit the dimension, position, and outline of the newly created
defect, unlike prefabricated or hingeover flaps which require
delay or intranasal lining flaps which may be precluded by
injury to their vascular base or the position of the defect. It is
a simple yet highly effective method.
Skin grafts for lining
Skin grafts have been used to line a forehead flap at the time
of transfer. Unfortunately, although a skin graft is thin and
pliable, revascularization is unpredictable. More often, a skin
graft has been applied to the forehead flap prior to transfer
during a preliminary prelamination (prefabrication) 6 weeks
before transfer. Later, when “take” was assured, the healed
forehead and underlying skin graft were transferred to the
recipient site. Graft shrinkage, in these poorly supported
noses, was accepted as a part of the technique.
Gillies developed a skin graft inlay method.16 If the lining
and support were lost but the overlying skin remained intact
(as in the syphilitic or leprotic saddle nose), internal scar was
released on the undersurface of the external skin and a skin
graft applied to the raw internal surface. A permanent internal
prosthesis, placed through a buccal fistula and fixed to den-
tures, splinted the graft to maintain airway patency and nasal
shape.

158.e1
The repair of nasal defects – treatment options
D
(D) The intermediate operation of the modified folded forehead flap. One
month later, the folded forehead flap lining extension is healed to the adjacent
normal nasal lining and is no longer dependent on the forehead flap for its
supratrochlear blood supply. The regional units of the nose an ideal alar margin are
marked with ink. The forehead flap is incised between covering lining along the
nostril margin and the covering flap was elevated with 2–3 mm of subcutaneous fat.
This exposes the underlying unsupported subcutaneous fat and frontalis muscle
which is excised from the underlying lining of folded forehead skin. A delayed
primary cartilage graft is positioned to support the ala (and sidewall, if needed).
The thin forehead flap is returned to the recipient site for nasal cover. One month
later (2 months after the initial flap transfer), the proximal pedicle is divided.
Fig. 6.31

158.e2
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
A
B
D
(ABD) A full-thickness defect of the right ala and sidewall is present after Mohs excision.
The regional units of the nose and the ideal alar base position are marked with ink based on the
template of the contralateral normal upper lip. Templates were designed to replace the missing cover
and lining exactly in dimension and border outline. A full-thickness forehead flap is elevated with the
distal extension for lining and folded to replace missing nasal lining and the more proximal distal
flap is turned back to resurface the defect. No primary cartilage grafts were placed. The raw pedicle
of the forehead flap was skin grafted for cleanliness.
Fig. 6.32

159
The repair of nasal defects – treatment options
D
E
A
Fig. 6.33  (ADEFG) One month later, the reconstruction is bulky and unsupported. The
lining extensions are now vascularized by the residual nasal lining and are no longer
dependent on the forehead flap for vascularity. The ideal nostril margin is marked with
ink and incised. The proximal forehead flap was elevated with 2–3 mm of subcutaneous
fat. The folded double layer of so and is fat and frontalis muscle is exposed. The excess
is excised in the lining skin is supported and shaped with a delayed primary conchal
cartilage graft. The thin forehead skin flap is returned to the defect and fixed with
quilting sutures and peripheral sutures.
F
G
Fig. 6.34  (C) Postoperative result after pedicle division and right alar crease
creation.
C

159.e1
The repair of nasal defects – treatment options
B
C
(BC) One month later, the reconstruction is bulky and
unsupported. The lining extensions are now vascularized by the residual
nasal lining and are no longer dependent on the forehead flap for
vascularity. The ideal nostril margin is marked with ink and incised. The
proximal forehead flap was elevated with 2–3 mm of subcutaneous fat.
The folded double layer of so and is fat and frontalis muscle is exposed.
The excess is excised in the lining skin is supported and shaped with a
delayed primary conchal cartilage graft. The thin forehead skin flap is
returned to the defect and fixed with quilting sutures and peripheral
sutures.
Fig. 6.33 
Fig. 6.34
B
(AB) Postoperative result after pedicle
division and right alar crease creation.
A

160
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
Fig. 6.35  (A–C) A healed central defect of the nasal tip after a dog bite. Covering skin, tip support, and lining for both vestibules is missing.
A
B
C
Fig. 6.36  (A–E) The defect is recreated. A
subunit excision of the tip, but not of the
dorsum, is performed. Tip support was
restored with septal cartilage extended,
lateral spreader grafts, a columellar strut,
and tip graft to lengthen the nose project
and shape the tip. Ear cartilage grafts were
positioned in subcutaneous pockets within
each alar remnant and fixed to the tip
repair to shape and support the nostril
margins. In lateral defects, unless an
expanded forehead flap is employed,
primary support of the ala is not
positioned at the time of transfer of a
folded forehead flap for cover and lining.
When the defect is central, the risk of
asymmetric rim retraction is significant
prior to the intermediate operation and
primary cartilage grafts are placed to
support the tip and nostril margins at the
time of forehead flap transfer. A
full-thickness folded forehead flap is
designed with bilateral extensions to line
the right and left nasal vestibule.
A
B
C
D
E

161
The repair of nasal defects – treatment options
B
C
Fig. 6.37  (BC) One month later, the cover and lining flaps are
separated along the ideal nostril margin and excess subcutaneous
fat and frontalis sculpted to refine the nasal shape. The forehead
flap is then returned to the recipient site.
Fig. 6.38  (ABC) Postoperative result without revision.
A
B
C
More recently, Burget22 tunneled a cartilage graft within the
subcutaneous fat between the frontalis and the external skin
of a forehead flap to repair modest nasal defects of the nostril
margin and ala at flap transfer. The cartilage survived within
the vascularized soft tissue and supported the nostril margin.
A full-thickness postauricular skin graft was sutured to the
lining defect, raw surface outward. The deep surface of the
frontalis muscle vascularized the underlying skin graft.
The buried cartilage graft “stented” the skin grafted lining,
much like the Gillies external splint.
In smaller unilateral defects, when significant residual skin
remained above the defect, a bipedicle flap of remnant ves-
tibular skin, based on the septum medially and laterally at the
alar base, was transposed inferiorly to the level of the pro-
posed alar margin. Because the marginal bipedicle flap had
its own blood supply, a primary cartilage graft was fixed to
its vascularized external surface. The secondary lining defect
above the vestibular flap was repaired with a full-thickness
skin graft. No primary cartilage was placed in this area. The
forehead flap resurfaced the entire defect and revascularized
the lining skin graft. Three to four weeks later, after the skin
graft lining was healed and vascularized from adjacent
residual lining, the superior ala and sidewall were supported
by a delayed primary cartilage graft placed at pedicle divi-
sion. The forehead flap, maintaining a pedicle from the
eyebrow to the distal flap inset along the nostril margin, could
also be re-elevated over the mid-vault during an intermediate
operation to allow delayed primary support. Scarring in the
vicinity of the internal valve, leading to nasal obstruction,
occasionally follows and is difficult to correct.
These skin grafts retained most of their original dimen-
sions. Some graft contracture occurs, causing minor distor-
tions. Simplicity is a primary advantage, making it especially
useful in an elderly or debilitated patient for whom more
complex intranasal dissection should be avoided, when intra-
nasal lining flaps are unavailable, or for the less demanding
patient who desires a simple and less delicate repair.
The three-stage full-thickness forehead flap has broadened
the applications of skin grafts for lining, based on principles
similar to those of the modified folded forehead flap
technique.
As described by Menick,25,74 a full-thickness forehead flap
is highly vascular and a skin graft will routinely “take” on its
deep raw surface. An exact pattern of the lining defect is

161.e1
The repair of nasal defects – treatment options
A
D
(AD) One month later, the cover and lining flaps are separated along
the ideal nostril margin and excess subcutaneous fat and frontalis sculpted to
refine the nasal shape. The forehead flap is then returned to the recipient site.
Fig. 6.37

162
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
applied prior to pedicle division to augment the lining surface
dimension. If a full-thickness forehead flap has been employed
initially, the flap is re-elevated during an intermediate opera-
tion; deficient lining at one or both alar bases is cut free. The
lining gap is filled with a full-thickness skin graft. The full-
thickness flap is reapplied without thinning to revascularize
the skin graft. Once healed in place, the forehead flap is
re-elevated thinly during a second intermediate operation,
excess soft tissue excised, and delayed primary grafts placed
to provide permanent support and shape over the augmented
skin graft lining, increasing the size of the airway.
Microvascular lining with distant tissue
Especially “difficult” facial wounds are defined by their site,
size, depth, and wound character (vascularity, contamination,
radiation, immunosuppression, and exposure of vital struc-
tures). Such complex and often combined injuries to the
adjacent cheek and lip may make local tissues inadequate or
unavailable for nasal repair. The volume of missing tissues
and the dimensions of the surface requirements must not be
underestimated. Large amounts of healthy vascularized tissue
will be needed to ensure primary healing. They require the
introduction of distant tissue, by microvascular transfer, to
re-establish the midface platform or to supply nasal lining.75
A regional forehead flap can provide covering skin, but distant
tissue, transferred as a microvascular flap, is used for lining
or facial bulk.
A preliminary operation may be required to first return
normal to normal, establish a stable platform, or delay or
reposition residual tissues prior to the nasal reconstruction.
Principles of free flap nasal reconstruction
1. If missing, the midface platform must be re-established
during a preliminary operation. When in doubt,
reconstruct the lip and cheek first and rebuild the nose
later. The nose must sit on a stable midface in the
correct position and with the correct projection.
2. The septal partition is not restored to avoid excessive
intranasal bulk and nasal obstruction. A septal fistula is
accepted.
3. Columellar lining is provided only to provide a soft
tissue pocket to position cartilage support and “back”
the raw surface of the future covering forehead flap. The
deeper septum is not restored.
4. The site and dimension of missing nasal lining must be
identified. The vault spans from alar base to alar base
and from the superior aspect of the defect to the base of
the columella. If completely absent, this measures
7–8 cm transversely and 4 cm vertically from the nasal
route to the tip with an additional 3 cm for the
columella. Re-establishment of vault lining is
straightforward because it must simply drape across a
central support which prevents its collapse into the
pyriform aperture. The columella must be long enough
to project the nose and narrow enough to maintain
patent airways. The nasal floor or sill is the skin platform
onto which the nose must be placed. In many cases, the
floor remains intact or has been previously restored
during a preliminary operation to build the nasal
platform. A floor deficiency may be obvious after
outlined and a full-thickness postauricular skin graft is
sutured to the margins of the lining defect. Primary cartilage
grafts are precluded between the skin graft and the undersur-
face of the flap. But support can be placed over intact lining,
adjacent to the full-thickness loss. It provides a vascular bed
for lining skin graft which is quilted to the overlying flap and
is also splinted with a sponge bolus, placed with the nostril
for 3–4 days to immobilize the repair and apply light pressure.
The full-thickness flap provides external cover. Support grafts
are not placed within soft tissue tunnels within the forehead
flap to avoid a thick nostril rim or the initiation of soft tissue
injury and scar. It is also difficult to design, position, or fix
tunneled cartilage grafts.
Four weeks later, the skin graft is healed to the adjacent
normal residual lining and is no longer dependent on the
covering flap for its blood supply. At the second stage, cov-
ering skin with 2–3 mm of subcutaneous fat is completely
elevated from the nose. Excess subcutaneous fat and frontalis,
which lie over the skin graft, are excised down to the newly
reconstructed lining. The skin graft is thin, relatively supple,
and vascularized by the adjacent residual lining. A delayed
primary alar margin batten graft is fixed to support the nostril
margin and a sidewall brace placed over the mid-vault to
prevent upward retraction if the defect extends upward. The
thin covering flap is replaced over the delayed primary carti-
lage grafts and the restored skin graft lining. Four weeks later
(8 weeks after forehead flap transfer), the pedicle is divided.
Occasionally, the skin graft fails. If so, the intermediate
stage is delayed and the granulating bed on the undersurface
of the forehead flap is sharply debrided and a second graft
applied. The forehead flap does not need to be re-elevated.
The skin graft is simply applied to its raw deep surface.
Because frontalis muscle is not excised and injury to the
subcutaneous plane of the full-thickness forehead flap spared,
fibrosis or contracture does not occur within the covering flap.
Although an additional stage is required to replace the skin
graft, the overall result is not significantly impaired.
The modified skin graft for lining technique is reliable,
efficient, and effective for the repair of small to moderate,
full-thickness nasal defects. Scar contracture and secondary
distortion are modest and a delicate alar rim can be created.
The technique should be limited to lining defects between
0.5–1.5 cm in size. Skin graft “take” is routine, although a
second graft may be required in 20–30% of cases. However,
an initial skin graft loss delays pedicle division from the
expected 8 weeks to 12 weeks. The risk of poor skin graft take
and contraction increases as the size of the lining defect
increases. The method is especially useful in the elderly or
debilitated patient with unassociated medical illness when
intranasal lining flaps should be avoided. Overall, as in the
folded flap technique for lining, morbidity is minimal.
Because equal or better results can be obtained with the
folded forehead flap lining technique, without the risk of skin
graft loss, it is preferred to the skin graft lining approach. The
folded technique can be applied to larger lining defects up to
3 cm. However, both methods are reliable, less complex,
shorten operating time, and are associated with minimal
morbidity.
The modified skin graft technique has its most important
application in salvage situations when lining is inadequate
after forehead flap transfer by any lining technique. Rather
than accept an inadequate airway, a lining skin graft can be

163
The repair of nasal defects – treatment options
excision or trauma, especially if an open wound is
present or, if, by history, the lip has suffered extensive
injury. It is less apparent after injury due to cocaine or
other intranasal processes. It may also be reconstructed
at the time of free flap transfer with local tissue or with
part of the free flap. Clinically, the upper lip is drawn
back and up, identified by displacement and posterior
angulation of the upper aspect of the lip. The tissue
deficiency must be released and skin replaced under the
future alar and columella inset.
5. The nasal reconstruction is planned in stages. Despite
Gillies’ admonition to employ “like” tissue, distant skin
for lining, bulky rib grafts for support, or a thick, flat
forehead flap for external cover are “unlike” the normal.
The challenge is to modify these disparate donor
materials into “nasal-like tissues” and integrate them
together, restoring each anatomic layer to recreate a
normal looking and functioning nose. The initial goal is
to supply lining for the inner surface of the nose during
a preliminary operation. Once in place, the distant
lining effectively turns a complex full-thickness defect
into a superficial one. Needed support and cover are
addressed later using traditional methods using regional
tissue.
6. Distant tissue can close dead space, fill a cavity, protect
vital structures, create a barrier between the central
nervous system and the oral cavity, close a fistula, or
build a stable platform. Microvascular distant flaps are
used to provide nasal lining and vascularity. Excess is
used to refill the wound and provide for other needs
– soft tissue cheek bulk, upper lip skin, nasal floor, etc.
However, distant tissue always appears as a
mismatched, discolored patch when it lies within
residual normal facial skin. No free flap has a facial
shape. Facial skin flaps, transferred as a forehead flap,
must provide matching covering skin with the correct
color and texture.
The midfacial defect with an inadequate platform
Often local or regional tissues are insufficient to restore a
defect of the nose, lip, and cheek. In smaller composite losses,
minor lip and cheek defects may be replaced with local tissues
or with extensions of the free lining flap. Distant tissue, often
harvested from the trunk, may be needed to provide sufficient
soft tissue and skin – a scapular, parascapular, latissimus, or
rectus flap – in larger defects.
The immediate goal of surgery is to provide an excess of
tissue with adequate bulk and projection, obliterating an open
maxillary sinus, if necessary. Both bone and soft tissue can be
supplied. The facial platform is restored initially. Nasal recon-
struction is delayed until a stable platform is restored.
Restoring nasal lining with a free flap
If the midface platform is stable, the nasal repair is begun.
Defects of the mid-vault alone
If the defect is limited to the nasal vault, only vault lining and
preliminary central support are required at the first stage.
Because of its thinness and long vascular pedicle, the radial
forearm flap is preferred.
If the septum is intact and the defect includes only the
mid-vault, the lining defect may be replaced with a free flap,
skin inward for lining. Its outer surface is skin grafted. If the
residual septum is intact with adequate height, it will tempo-
rarily support the lining flap until definitive placement of
additional cartilage grafts and a covering forehead flap are
placed in the future.
If the septum remains but has been partially resected, it can
be swung out of the nasal cavity as an inferiorly based com-
posite septal flap during a preliminary operation. Then the
free flap is transferred for lining, once vascularity of the
composite flap is assured.
If the majority of the septal partition is missing, it is not
reconstructed. Local or distant tissue is too thick to replace the
septum without creating airway obstruction. The surgeon
only provides lining for the vault and backing for the colu-
mella. A permanent septal fistula is accepted. The flap is
folded over onto itself along the future nostril margin. This
allows placement of an autogenous dorsal cantilever bone
graft for immediate central support. Subsequently, during the
definitive nasal repair, the external skin graft or folded skin is
excised. A complete subunit support framework is placed and
the nose is resurfaced with a forehead flap.
Subtotal and total nasal defects: lining for the vault,
columella, and nasal floor
Distant tissue has been transferred as cutaneous, composite
helical, osteocutaneous, prelaminated, or prefabricated free
flaps – with limited application and success.59,60 The exception
is the work of Burget and Walton26,77–79 that employed multiple,
longitudinally oriented forearm skin paddles to repair nasal
defects. Two or three separate skin flaps were positioned, skin
inward, to individually line the vault, columella, and nasal
floor. Each paddle was vascularized by the underlying radial
vessel, like a “string of beads”. Their external raw surfaces
were covered with full-thickness skin grafts, precluding
primary soft tissue support. Later, the individual skin paddles
were sutured together, thinned, supported with cartilage
grafts, and resurfaced with a distally thinned two-stage fore-
head flap. During a subsequent operation prior to pedicle
division, forehead skin was elevated over the mid-vault and
soft tissue was excised over the superior two-thirds of the
nose, as described by Millard. A second intermediate opera-
tion was performed to debulk the airways. Later, the pedicle
was divided and a revision performed. Good results were
obtained during six or more operations (Fig. 6.39).
However, limitations9 are apparent. Elevating three sepa-
rate paddles for the vault, columella, and nasal floor is techni-
cally tedious and leaves a short proximal vascular pedicle for
anastomosis. Injury to the vascular pedicle during elevation,
or kinking during positioning of these multiple paddles,
could jeopardize blood flow. The vascular pedicle to each
paddle is also exposed to injury during subsequent stages,
which may compromise blood supply, already limited by the
scars between the skin islands. The cutaneous scars between
each paddle may lead to skin contraction and limit the supple-
ness of the lining. Because primary support cannot be placed
under the initial external skin grafts, soft tissue collapse and
skin shrinkage occurs. Most importantly, no excess tissue is
available to salvage an imperfection in lining design or a
complication.

164
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
Fig. 6.39  The Burget and Walton approach to microvascular nasal lining. Individual radial forearm flap paddle design to individually replace nasal vault, columellar, and
nasal for lining. Islands of skin, each perfused by the radial artery, are designed like a “string of beads” to supply lining for the nasal vault, columellar, and nasal floor. Their
unsupported external surfaces are temporarily covered with full-thickness skin grafts. Later, the skin grafts are excised, excess forearm subcutaneous fat excised, individual
paddles sutured together to complete the lining, primary cartilage grafts are placed, and the nose resurfaced with a distally thin forehead flap. During an intermediate
operation, the flap is elevated over the mid-vault to allow local soft tissue debulking, maintaining the proximal supratrochlear pedicle in the distal inset of the flap to the
columella tip and ala.
C
D
A
B
Facial artery
and vein
Paddle 1
1
Paddle 2
2
Paddle 3
3
1
Radial artery and vein
2
3

165
The repair of nasal defects – treatment options
is thinned in stages. Precise contouring of the mid-vault is
impeded by the bipedicle flap, which limits exposure. Most
importantly, the contour of the distal inset – the most aesthetic
part of the nose, is fixed. The shape of tip, ala, and columella
cannot be altered after initial forehead flap transfer.
Menick and Salibian80 described a folded single paddle
forearm flap approach, combined with a three-stage full-
thickness forehead flap for cover, which is a reliable, efficient
microvascular design, applicable to varied defects (Figs.
6.40–6.46
).14
Figs. 6.42A,B,C, 6.43B,D, 6.44A,B,F, 6.45B,D,F,H, and 6.46B
appear online only.
The use of a two-stage forehead flap, with an intermediate
operation, was originally suggested by Millard66 in 1974. He
combined traditional distal thinning of a forehead flap with an
additional operation, prior to pedicle division. The forehead
flap was elevated over the mid-vault as a bipedicle, maintaining
the tip, alar, and columellar inset. The superior two-thirds of
the nose was reshaped. However, this forehead flap approach,
which combines initial distal thinning of forehead flap and
subsequent mid-vault elevation, has several disadvantages.
Initial distal excision of frontalis muscle may decrease the
overall blood supply to the forehead flap. It is more difficult
to create a thin uniform skin flap when the forehead flap
A
Radial artery and vein
Distal flap folded
under to line vault
and columella
Extension sweeps under
to surface floor
X
X
X
X
Fig. 6.40  The Menick and Salibian approach to microvascular lining. Nasal lining is designed as a distal single paddle radial forearm flap with an extension for the nasal
floor. The flap is folded inward to line the columella and vault, the floor extension spontaneously rotates to resurface the nasal floor. More proximal skin is turned back to
provide cover, creating a soft tissue pocket which allows for placement of primary dorsal support at the initial stage. Later, external radial skin can be hinged inferiorly to
permit adjustments in the nostril margin of alar base position. Excess radial forearm subcutaneous tissue is excised, maintaining the radial artery pedicle intact. A complete
subunit support framework is added to shape the columella, tip alar margins, and sidewalls. The repair is covered with a full-thickness forehead flap. During a subsequent
intermediate operation the forehead skin is elevated completely, maintaining the supratrochlear pedicle. The underlying soft tissues are excised to sculpt a 3D shape over
the entire nasal surface and permit placement or adjustments of cartilage grafts. The “thinned” flap is returned to the contoured recipient site and the pedicle later divided.
Radial vessels
Columellar strut
Folded-down skin lining
Alar margin
batten grafts
Tip graft
Full-thickness
forehead flap
Full-thickness
forehead flap with
frontalis muscle
Primary dorsal graft
Supratrochlear
artery
External skin
hinged over
B

166
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
A
Fig. 6.41  (AB) Subtotal nasal defect after cancer excision and
initial bilateral nasolabial flaps to resurface the upper lip.
B
D
Fig. 6.42  (DE) A rib cartilage graft was fixed to the residual nasal bones to provide primary dorsal support and prevent soft tissue shortening and collapse. Because the
missing nasal floor had been repaired with nasolabial flaps, a microvascular radial forearm flap was designed without a distal extension for the nasal floor. Its ulnar border is
folded inward to create columella and pulled lining. The skin extension resurfaces the nasal floor. More proximal forearm skin and the radial vessels are turned back to
provide temporary cover and permit placement of a primary dorsal osteocartilaginous graft.
E
Operation 1
A pattern of the lining defect is positioned on the forearm and
face to verify the flap’s size, outline, orientation, pedicle
length, area of folding, and the position of the skin extension
for the nasal floor.
A single, horizontally oriented paddle of forearm skin
(8–10 cm in width and 6–8 cm in height), is outlined on the
distal forearm, with or without a proximal extension for the
nasal floor.
The flap can be raised as a skin flap, maintaining only
fasciocutaneous connections over the radial vessels. However,
it is safer to limit primary fascial excision to maintain
maximum blood supply. An extension for the nasal floor can
be designed vertically, in continuity with the primary flap, just
distal to the future site of infolding, if the defect includes the
vault, columella, and nasal floor. This positions the extension
to resurface the floor when the primary flap is turned inward
for lining. Because the single skin paddle is placed distally on

166.e1
The repair of nasal defects – treatment options
A
B
C
(ABC) A rib cartilage graft was fixed to the residual nasal bones to provide primary dorsal support and prevent soft tissue shortening and collapse. Because the
missing nasal floor had been repaired with nasolabial flaps, a microvascular radial forearm flap was designed without a distal extension for the nasal floor. Its ulnar border is
folded inward to create columella and pulled lining. The skin extension resurfaces the nasal floor. More proximal forearm skin and the radial vessels are turned back to
provide temporary cover and permit placement of a primary dorsal osteocartilaginous graft.
Fig. 6.42

167
The repair of nasal defects – treatment options
later provide a posterior backing for the columellar extension
of the forehead flap. The septal partition is not restored.
The distal skin is folded under the more proximal skin flap
to line both vaults. The lateral, distal tips of the flap are fixed
to the midline of the lining defect and then sutured toward
the alar bases, from medial to lateral, completing the inset.
The height of the columella and dimension of the vault are
adjusted, and slightly exaggerated, by altering the extent of
infolding. As the flap folds inward to line the vault, the skin
extension spontaneously rotates inward to resurface the floor.
The reconstructed columella is inset in the midline to the
the forearm, a 12–15-cm arterial pedicle and a longer venous
pedicle (extended through the communicating vein from the
venae comitantes to the cephalic vein) are available. Large
high flow recipient vessels may be preferred. The microvas-
cular anastomoses is made to the first branch of the external
carotid artery and the internal jugular vein or external jugular
vein as recipients. The superficial temporal artery and external
jugular vein or facial vessels are used in the short fat neck.
The thin, distal ulnar edge of the forearm flap is pinched
together in the midline, suture approximating its posterior
raw surface to “manufacture” a skin columella which will
A
Fig. 6.43  (AC) Two months later, external radial skin
is hinged inferiorly. The reconstructed “columella” is
split in the midline. The nostril margin and alar base
insets are adjusted. The radial vessels are left adherent
to the underlying folded lining. Excess forearm soft
tissue is excised to thin the lining.
C
Fig. 6.44  (CDE) Subunit support is completed with a columellar strut, tip graft, and bilateral alar margin rib grafts. The
repair is resurfaced with a full-thickness forehead flap.
C
D
E

167.e1
The repair of nasal defects – treatment options
B
D
(BD) Two months later, external radial skin is hinged inferiorly. The
reconstructed “columella” is split in the midline. The nostril margin and alar base
insets are adjusted. The radial vessels are left adherent to the underlying folded lining.
Excess forearm soft tissue is excised to thin the lining.
Fig. 6.43

167.e2
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
A
B
F
(ABF) Subunit support is completed with a columellar strut, tip graft, and bilateral alar margin rib grafts. The repair is
resurfaced with a full-thickness forehead flap.
Fig. 6.44