Vạt Da Và Phẫu Thuật Tái Tạo (Flaps and Reconstructive Surgery)

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72. Yuen JC, Feng Z. Monitoring free flaps using the laser Doppler
flowmeter: five-year experience. Plast Reconstr Surg 2000;105(1):
55–61.
73. Heller L, Levin SL, Klitzman B. Laser Doppler flowmeter monitor­
ing of free-tissue transfers: blood flow in normal and complicated
cases. Plast Reconstr Surg 2001;107(7):1739–45.
74. Krishnan KG, Schackert G, Steinmeier R. The role of near-infrared
angiography in the assessment of post-operative venous congestion
in random pattern, pedicled island and free flaps. Br J Plast Surg
2005;58(3):330–8.
75. Yamaguchi S, De Lorenzi F, Petit JY, et al. The “perfusion map” of
the unipedicled TRAM flap to reduce postoperative partial necro­
sis. Ann Plast Surg 2004;53(3):205–9.
76. Hwang JH, Mun GH. An evolution of communication in postopera­
tive free flap monitoring: using a smartphone and mobile mes­
senger application. Plast Reconstr Surg 2012;130(1):125–9.
77. Engel H, Huang JJ, Tsao CK, et al. Remote real-time monitoring of
free flaps via smartphone photography and 3G wireless internet: a
prospective study evidencing diagnostic accuracy. Microsurgery
2011;31(8):589–95.
78. Nakatsuka T, Harii K, Asato H, et al. Analytic review of 2372 free
flap transfers for head and neck reconstruction following cancer
resection. J Reconstr Microsurg 2003;19:363–8.
79. Kroll SS, Schusterman MA, Reece GP, et al. Timing of pedicle
thrombosis and flap loss after free-tissue transfer. Plast Reconstr
Surg 1996;98:1230–3.
80. Bui DT, Cordeiro PG, Hu QY, et al. Free flap reexploration: indica­
tions, treatment, and outcomes in 1193 free flaps. Plast Reconstr
Surg 2007;119(7):2092–100.
81. Ritter EF, Cronan JC, Rudner AM, et al. Improved microsurgical
anastomotic patency with low molecular weight heparin. J Reconstr
Microsurg 1998;14(5):331–6.
82. Sun TB, Chien SH, Lee JT, et al. Is dextran infusion as an anti­
thrombotic agent necessary in microvascular reconstruction of
the upper aerodigestive tract? J Reconstr Microsurg 2003;19(7):
463–6.
83. Peter FW, Franken RJ, Wang WZ. Effect of low dose aspirin on
thrombus formation at arterial and venous microanastomoses and
on the tissue microcirculation. Plast Reconstr Surg 1997;99(4):
1112–21.
84. Kuo YR, Jeng SF, Wang FS. Platelet glycoprotein IIb/IIIa receptor
antagonist (abciximab) inhibited platelet activation and promoted
skin flap survival after ischemia/reperfusion injury. J Surg Res
2002;107(1):50–5.
85. Panchapakesan V, Addison P, Beausang E, et al. Role of thromboly­
sis in free-flap salvage. J Reconstr Microsurg 2003;19(8):523–30.
86. Yii NW, Evans GR, Miller MJ, et al. Thrombolytic therapy: what is
its role in free flap salvage? Ann Plast Surg 2001;46(6):601–4.
87. Atiyeh BS, Hashim HA, Hamdan AM, et al. Local recombinant
tissue plasminogen activator rt-PA thrombolytic therapy in micro­
vascular surgery. Microsurgery 1999;19:261–5.
88. Jokuszies A, Neubert N, Herold C, et al. Early start of the dangling
procedure in lower extremity free flap reconstruction does not
affect the clinical outcome. J Reconstr Microsurg 2013;29(1):
27–32.
89. Ridgway EB, Kutz RH, Cooper JS, et al. New insight into an old
paradigm: wrapping and dangling with lower-extremity free flaps.
J Reconstr Microsurg 2010;26(8):559–66.
90. Xipoleas G, Levine E, Silver L, et al. A survey of microvascular
protocols for lower extremity free tissue transfer II: postoperative
care. Ann Plast Surg 2008;61(3):280–4.
51. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin
therapy in critically ill patients. N Engl J Med 2001;345(19):
1359–67.
52. Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin
therapy in the medical ICU. N Engl J Med 2006;354(5):449–61.
53. Finfer S, Chittock DR, Su SY, et al. Intensive versus conventional
glucose control in critically ill patients. N Engl J Med 2009;
360(13):1283–97.
54. Moghissi ES, Korytkowski MT, DiNardo M, et al. American Associa­
tion of Clinical Endocrinologists and American Diabetes Associa­
tion consensus statement on inpatient glycemic control. Diabetes
Care 2009;32(6):1119–31.
55. Bratzler DW, Houck PM, et al. Antimicrobial prophylaxis for
surgery: an advisory statement from the National Surgical Infection
Prevention Project. Am J Surg 2005;189(4):395–404.
56. American Society of Health-System Pharmacists. ASHP therapeutic
guidelines on antimicrobial prophylaxis in surgery. Am J Health
Syst Pharm 1999;56:1839–88.
57. Liu DZ, Dubbins JA, Louie O, et al. Duration of antibiotics after
microsurgical breast reconstruction does not change surgical infec­
tion rate. Plast Reconstr Surg 2012;129(2):362–7.
58. Hecker MT, Aron DC, Patel NP, et al. Unnecessary use of antimi­
crobials in hospitalized patients current patterns of misuse with an
emphasis on the antianaerobic spectrum of activity. Arch Intern
Med 2003;163:972–8.
59. Toia F, D’Arpa S, Massenti MF, et al. Perioperative antibiotic pro­
phylaxis in plastic surgery: a prospective study of 1,100 adult
patients. J Plast Reconstr Aesthet Surg 2012;65(5):601–9.
60. Coon D, Tuffaha S, Christensen J, et al. Plastic surgery and smoking:
a prospective analysis of incidence, compliance, and complications.
Plast Reconstr Surg 2013;131(2):385–91.
61. Eberlein TJ, Crespo LD, Smith BL. Prospective evaluation of imme­
diate reconstruction after mastectomy. Ann Surg 1993;218:29.
62. Chang DW, Reece GP, Wang B, et al. Effect of smoking on compli­
cations in patients undergoing free TRAM flap breast reconstruc­
tion. Plast Reconstr Surg 2000;105(7):2374–80.
63. Rinker B. The evils of nicotine: an evidence-based guide to smoking
and plastic surgery. Ann Plast Surg 2013;70(5):599–605.
64. Manchio JV, Litchfield CR, Sati S, et al. Duration of smoking ces­
sation and its impact on skin flap survival. Plast Reconstr Surg
2009;124(4):1105–17.
65. Genden EM, Rinaldo A, Suárez C, et al. Complications of free flap
transfers for head and neck reconstruction following cancer resec­
tion. Oral Oncol 2004;40(10):979–84.
66. Torre J, Hedden WH, Grant PM, et al. Retrospective review of the
internal Doppler probe for intra- and postoperative microvascular
surveillance. J Reconstr Microsurg 2003;19:287–90.
67. Swartz WM, Izquierdo R, Miller MJ. Implantable venous Doppler
microvascular monitoring. Plast Reconstr Surg 1994;93:152–63.
68. Smit JM, Whitaker IS, Liss AG, et al. Post operative monitoring of
microvascular breast reconstructions using the implantable Cook-
Swartz Doppler system: a study of 145 probes and technical discus­
sion. J Plast Reconstr Aesthet Surg 2009;62:1286–92.
69. Swartz WM, Jones NF, Cherup L, et al. Direct monitoring of micro-
vascular anastomoses with the 20 mHz ultrasonic Doppler probe:
an experimental and clinical study. Plast Reconstr Surg 1988;81:
149–58.
70. Paydar KZ, Hansen SL, Chang DS, et al. Implantable venous Doppler
monitoring in head and neck free flap reconstruction increases the
salvage rate. Plast Reconstr Surg 2010;125(4):1129–34.
71. Smit JM, Klein S, de Jong EH, et al. Value of the implantable
doppler system in free flap monitoring. J Plast Reconstr Aesthet
Surg 2012;65(9):1276–7.

357
Reconstructive Options
Following Flap Failure
Michael J. Miller  |  Rajiv Chandawarkar
30 
INTRODUCTION
A failed free flap is a challenge for every microsurgeon
no matter how experienced. When a flap is lost, the patient
and family are disappointed, and disturbed over the need
for additional surgery. The clinical support staff share a
sense of responsibility and discouragement. The surgeon
must make difficult clinical decisions. There are often
several reconstructive surgical options, the array seems con­
fusing – simpler methods (skin graft) seem “second-choice”
(though there is a great desire and hurry to get the patient
healed and discharged), while more complex options
(another free flap) seem daunting and fraught with a
second loss. Although the rates of failure are low,1,2 every
microvascular case can potentially succumb to the “perfect
storm.” An array of reasons for failure exist, and vary
depending upon anatomic region and types of reconstruc­
tion – and have been elucidated in this book as well
elsewhere.3–6 To be fully prepared with an alternative “plan
B” – a well-defined post-failure strategy is essential for every
microsurgeon and for every case.7,8 It is a sure-footed
approach, which greatly reduces the stress of decision-
making. It has a redeeming, confidence-boosting effect for
both the patient and the surgeon. For a patient who has
undergone flap failure, partial or complete, either immedi­
ately after surgery or following what might have appeared
to be a successful flap transfer, the following reconstructive
questions bear discussion:
• When is a conservative reconstructive approach (poten­
tially associated with a suboptimal result yet ensuring a
safer recovery) justifiable?
• Can less than optimal methods of reconstruction, ones
that were thought to be inadequate when the first proce­
dure was performed, treat these problems successfully?
• Does the overwhelming concern about another potential
free flap failure deter surgeons from taking a hard deci­
sion of performing another free flap?
• When is it justifiable to undertake another free flap to
replace the previously failed one and risk another possi­
ble failure?
• What specific flap must be selected as the mode of a sec­
ondary reconstruction?
• If free flap, then what are the metrics that decide the
selection of recipient vessels?
• What adjunctive treatments are deployed to ensure sur­
vival after one failed flap chemotherapeutic interven­
tions (heparin, dextran, and aspirin), to improve the
outcome of these flaps?
In order to address these questions, we describe a frame­
work that comprises three aspects:
1. Patient-centered decision-making: A sensitive patient-centered
five-step decision-tree based firmly on the patient’s condi­
tion and need and a root cause analysis of flap failure
2. Reconstructive choices: A matched-list of available flap
reconstructive options (both free and non-microsurgical)
– to help proper selection of a reliable secondary recon­
structive strategy
3. Pearls and pitfalls that help survival of the second flap.
In this chapter we will consider each of these issues in
detail.
PATIENT-CENTERED DECISION-MAKING
Patient-centered decision-making involves five steps (Fig.
30.1).
STEP ONE: CLINICAL STATUS OF THE PATIENT
An honest appraisal of the patient’s medical status is a criti­
cal component of the way forward. Typically, the patient has
undergone one long primary operation (a resection with a
microsurgical reconstruction), an arduous recovery (punc­
tuated with the sentinel event of flap failure), and then a
re-exploration for salvage (which has also failed). At this
stage, the patient could be quite compromised, and under­
taking another long procedure right away may be ill-advised.
If the patient is medically unstable, then repeat surgery must
be deferred. Even a totally failed flap can serve as a biologi­
cal dressing for 10 days or more. Most often, this is not
necessary, and emergency re-exploration confirms irrevers­
ible pedicle thrombosis. At this time, immediate repeat
reconstruction is usually performed, especially if loss of the
flap results in exposure of vital structures. If, for some
reason, repeat major surgery is not advisable, then the
necrotic portions of the flap can be debrided and the wound
temporarily dressed until a repeat reconstruction can be
PART 3  —  RECONSTRUCTION
SECTION C  —  PRE AND POSTOPERATIVE MANAGEMENT

358
PART 3 — RECONSTRUCTION
to attempt another free tissue transfer, but it is a discipline
that improves the technical abilities of the surgeon.
A root cause analysis (RCA) provides the tools for a sys­
tematic approach. Root cause analysis is a structured method
used to analyze serious adverse events. Initially developed
to analyze industrial accidents, RCA is now widely deployed
as an error analysis tool in health care.9 A central tenet of
RCA is to identify underlying problems that increase the
likelihood of errors, while avoiding the trap of focusing on
mistakes by individuals. RCA thus uses the systematic
approach to identify both ACTIVE ERRORS (errors occur­
ring at the point of interface between humans and a complex
system) and LATENT ERRORS (the hidden systemic prob­
lems that contribute to adverse events). This step is critical
to decision-making for the secondary reconstruction.
performed under more suitable circumstances. This course
is indicated when the patient’s general medical condition is
unfavorable or if preferable for the patient to have an
opportunity to participate in a complicated decision-making
process. If ultimate failure of all or a portion of the flap
would result in an unacceptable recurrent defect, then early
debridement of all compromised tissue and repeat recon­
struction offers a speedy recovery. If it appears likely that
critical portions of the flap have a good chance of survival,
then surgery can be delayed to allow maximal tissue salvage
and clear delineation of the remaining defect.
STEP TWO: ROOT CAUSE ANALYSIS OF
FLAP FAILURE
If you don’t ask the right questions, you don’t get the right
answers.
(EDWARD HODNETT)
When analyzing the causes of free flap failure, a thorough
review of microsurgical principles coupled with a candid
effort to identify possible breaches in technique is manda­
tory. This not only helps one to decide whether it is prudent
Figure 30.1  Patient-centered decision-making tree. Involving five
steps, this algorithm allows for an objective decision to be reached
for patients with a failed first free flap reconstruction.
Favorable
Unfavorable
Unfavorable
Unfavorable
Unfavorable
Unfavorable
Step 1: Patient’s clinical status
Favorable
Step 2: Root cause analysis
Favorable
Step 3: Defect
Favorable
Step 4: Recipient vessels
Step 5: Flap availability
Second
free flap
Non-
microsurgical
reconstruction
Pearl
If failure is attributable to a clearly avoidable cause,
then undertaking a second free flap reconstruction is
feasible. In sharp contrast, if the cause is an unavoid-
able problem, a more conservative approach may be
the only way the defect can be reconstructed.
In order to help elucidate the issue of avoidable versus
unavoidable causes of failure, a brief synopsis of the common
causes is presented.
All free flap failures ultimately result from platelet aggre­
gation at the microvascular anastomosis (in patients with
normal clotting function). The list of factors that lead to
this sentinel event is classified into three main categories
(Box 30.1).
SYSTEMIC FACTORS
Typically, the systemic factors are directly related to comor­
bid conditions that the patient suffers and which adversely
affect flap survival. Low-flow states, such as cardiac disease,
labile hypertension, dehydration, renal failure, and periop­
erative hypovolemia, vasoactive medications, or recreational
drugs that result in vasoconstriction, hypotension, or altered
flow to the flap; hypoxia (from COPD), or restrictive pulmo­
nary disease, are possible causes.
Usually they constitute unavoidable causes of flap failure
(an exception being perioperative hypovolemia and dehy­
dration, which are correctable) – and steer decision-making
away from another free flap reconstruction that could fail
again. In most patients with systemic causes of failure, it is
safer to choose a non-microsurgical simpler reconstructive
strategy and return for a more definitive reconstruction
after the factors that led to flap failure have been mitigated.
Systemic disorders are associated with poor wound healing
or the unacceptable risks of morbidity such as myocardial
infarction, stroke, respiratory failure, etc. Flap failure is
related to conditions that cannot be immediately reversed
such as severe malnutrition or morbid obesity pose a cir­
cumstance in which a non-microsurgical alternative may be
most prudent. Each patient must be individually assessed
for the possible effect of comorbid conditions and the risk
and benefits of repeat microsurgery must be thoughtfully
weighed. Equally important is to consider the patients’ func­
tional recovery in the setting of comorbid conditions that
the patient has inherently.10

CHAPTER 30 — Reconstructive Options Following Flap Failure
359
the risk of vascular disease15 in vessels located in the treat­
ment fields. Patients with vascular malformations can also
pose problems due to abnormal local vasculature and clot­
ting abnormalities. Performing microvascular surgery on
diseased vessels requires meticulous attention to technical
details. When a flap fails despite proper technique and adju­
vant systemic anticoagulation, then it is usually prudent to
salvage the reconstruction using non-microvascular methods.
Thrombophilia
Hypercoagulable states are associated with a variety of inher­
ited and acquired conditions affecting platelet function or
peptides in the clotting cascade. Inherited disorders include
conditions such as factor V Leiden, protein C and S deficien­
cies, heparin-induced thrombocytopenia (HIT; especially
when heparin is used indiscriminately either during or after
the operation), and antithrombin and prothrombin muta­
tions.16 Although uncommon, they may account for throm­
bosis that is difficult to control in surgical patients17 and lead
to poor outcomes. Acquired hypercoagulability is associated
with trauma, infection, severe emotional distress, collagen
vascular diseases, and cancer. Hormonal contraceptives and
replacements promote thrombophilia in women.18 Cancer,
particularly breast and head and neck, is associated with
disorders of hemostasis related to abnormal activation of the
coagulation pathways, enhanced platelet aggregation and
activation, and decreased synthesis of antithrombin III and
protein C.19 Head and neck cancer patients can have both
preoperative hypercoagulability20 and postoperative throm­
bophilia21 due to alterations in clotting profiles related to
the underlying malignancy as well as major surgery. If sig­
nificant disorders of hemostasis are suspected or confirmed
following a failed free tissue transfer, then repeat microvas­
cular procedure has a high likelihood of a poor outcome
and an alternative procedure should be considered.
STEP THREE: CHARACTERIZE THE DEFECT
An essential part of planning any reconstructive procedure
is to identify the specific anatomic and functional elements
involved in the defect and prioritize them for repair. Four
critical questions arise:
1. What is the location of and anatomic complexity of the
defect?
2. Are vital structures exposed?
3. Is it associated with a functional disability?
4. What is the quality of the tissue bed?
In some sites (e.g., head and neck), functional priorities
may take precedence over aesthetic ones. In these situa­
tions, early closure is imperative and non-microsurgical
salvage may be a quicker and effective solution.22 In others
(e.g., breast reconstruction) aesthetic goals may take prece­
dence. It is never possible to achieve every conceivable goal
for a perfect restoration. There are always trade-offs. Thus,
the task of the surgeon is to consider which objectives are
most important, formulate a menu of surgical options, and
choose a method most likely to achieve the essential goals
in the simplest fashion with the least risk.
After a failed free flap, the patient again has an unre­
constructed or “recurring” defect that requires a diverse
EXTRALUMINAL FACTORS
Even a technically perfect microanastomosis will thrombose
if flow is reduced in the hours and days following surgery.
The most common cause of reduced flow is mechanical compression
of the vascular pedicle. Largely, these factors arise from the
local tissues directly adjacent to the flap, and cause vascular
compromise. They typically include external pressure from
catheters, tape, dressings, tissue edema, improper position­
ing, and hematoma formation adjacent to the vascular
pedicle.11 Last but not the least, prolonged surgery may add
to the risks of complications.12
INTRALUMINAL FACTORS
Vascular disease involving the donor or recipient vessels may
render them prone to thrombosis, despite optimal microsur­
gical technique and postoperative management. Intima-
media thickening, the precursor lesion of atherosclerosis,
may begin in adolescence, but definite atherosclerosis tends
to appear after the age of 40 in men, and the onset of meno­
pause in women.13 In the carotid system, a common recipi­
ent vessel location for head and neck free flaps, the incidence
of asymptomatic atherosclerosis can be as high as 80%,
depending on patient age, gender, and associated hyperten­
sion, cigarette smoking, and diabetes mellitus.14 Incidence
in the lower extremities is similar. Radiotherapy increases
Box 30.1  Causes of Flap Failure
Systemic Factors
• Low flow states
• Drugs
• Hypoxia
• Comorbid disease
• COPD
• Hypercoagulable states
• Impaired wound healing state
• Diabetes
• Renal failure
• Stroke
• Steroid use
Extraluminal Factors
• Pressure
• Hematoma
• Postop positioning
• Dressings, tapes, masks
• Catheter drains
• Edema
• Fibrosis
• Twist/kink
• Tissue tension
Intraluminal Factors
• Intimal inversion
• Atherosclerosis
• Rheologic currents
• Embolism
• Suture exposure
• Radiation
• Vascular malformations
• Thrombophilia

360
PART 3 — RECONSTRUCTION
surgery?24 Alternative donor sites can be selected to contain
similar tissues as the original donor area but with adjust­
ments made based on possible factors that might have con­
tributed to failure associated with previous donor site
selection (Fig. 30.2). Donor areas supplied by short, small
vessels (e.g., sophisticated perforator flaps) may be altered
to include more tissue and longer, large-caliber vessels. If
this results in a reconstruction with excessive soft tissue bulk,
then plans can be made for subsequent revisions. Compos­
ite tissue flaps (e.g., fibula osteocutaneous free flaps) may
be simplified to flaps containing only soft tissues (e.g.,
rectus abdominis musculocutaneous flaps), ALT for breast
reconstruction.25 Propeller flaps based on pivoted perfora­
tor vessels are elegant options for salvage.26 In head and
neck reconstruction, the trade-off in this decision may be a
less functional reconstruction but greater chance of achiev­
ing a healed wound with vital structures protected, oral
armamentarium of reconstructive options.23 The surgeon
must face the same set of decisions regarding treatment but
is armed with more information about the patient and
perhaps a different set of options from which to select.
Decision-making mandates even greater thoughtfulness,
and some original goals may have to be abandoned when
planning the salvage procedure. A good example is treat­
ment of an irradiated wound. A vascularized tissue transfer
is more reliable than a split-thickness skin graft or primary
closure in these circumstances. For this reason, a free tissue
transfer may be selected for a primary reconstruction. In the
event of failure due to irreversible factors, the surgeon
might be forced to resort to skin grafting and accept
decreased reliability, function, and aesthetic results. An
important consideration is the consequence of failure.
Failure of a split-thickness skin graft on a wound consisting
of muscle and subcutaneous tissue is less consequential than
if failure leads to exposed vital structures (e.g., major vascu­
lar structures, dura mater, etc.). If the consequences of
failure are low risk, then an acceptable trade-off can be to
use a less reliable method of reconstruction. If the conse­
quences are unacceptable, then every effort must be made
to perform a repeat microsurgical reconstruction under
optimized circumstances. It is difficult to generalize about
these decisions. Every case must be individually evaluated.
STEP FOUR: ASSESS THE RECIPIENT VESSELS
If appropriate donor tissue is available, then recipient vessels
are selected. This is the most important decision in a repeat
microsurgical operation. Previously used vessels may be con­
sidered if flap failure cannot be attributed to some feature
associated with them such as inadequate flow or vascular
disease. If prior failure was related to small, low-flow recipi­
ent vessels, then a repeat free flap should be planned, based
on large, high flow vessels. In certain circumstances, vein
grafts to high flow vessels (e.g., external carotid artery or
common femoral artery) can be more reliable than a direct
pedicle anastomosis to small recipient vessels. They can also
be used to reach locations away from vessels affected by
vascular disease caused by atherosclerosis or radiation. The
flap pedicle itself can be used as recipient vessels if flap
failure involves only a portion of the flap (e.g., the skin
paddle of a composite bone flap), or if it is related to factors
intrinsic to the flap design and not to the microanastomosis.
If this option is chosen, then it is best to delay surgery until
after the endothelium has healed (i.e., 7 days), so there is
less chance for thrombosis when flow is stopped during
repeat surgery.
If suitable donor tissue and recipient vessels are available
and a repeat microvascular reconstruction is planned, then
careful attention must be given to avoiding all ancillary pos­
sible factors that might have contributed to the previous
failure. Anticoagulation is not necessary unless indicated
based on previous influences based on diseased vessels or
coagulopathies.
STEP FIVE: EXAMINE RECONSTRUCTIVE CHOICES
More complicated defects are associated with longer lists of
possibilities. The critical question always is will the func­
tional and cosmetic goals be met following the second
Figure 30.2  Reconstructive choices. Matched list of flap choices
available for the failed free flap reconstruction (categorized by ana­
tomic regions).
SGAP, IGAP
ALT
TUG
Latissimus flap ±
implant
ALT, SCIP
Breast
PMMC
Supraclavicular
Trapezius
Sternocleidomastoid
Deltopectoral
Forehead
Contralateral ALT
RFF
Latissimus
Lateral arm
Contralateral
Fibula
Head and neck
Propeller
Fasciocutaneous
Reverse sural
Medial sural
Medial plantar
Dorsalis pedis
ALT
Rectus abdominis
SCIP
Lateral arm
RFF
Foot and
lower extremity
Upper extremity
Graft, groin flap

CHAPTER 30 — Reconstructive Options Following Flap Failure
361
device. The sponge conforms to the wound surface con­
tours and permits fluids to be drawn through and away from
the wound environment. The dressing is changed every 3
days depending on the level of drainage and level of concern
regarding potential wound contamination. Once a continu­
ous bed of granulation tissue is established on the wound
surface, it may be covered with a split-thickness skin graft or
local flap. The system may be used to bolster and stabilize
a skin graft.
Healing by secondary intention is accelerated with the
negative pressure system. The mechanism of action is not
completely understood, but a variety of mechanisms are
believed to be active. Subatmospheric pressure increases
blood flow while decreasing local edema and bacterial
counts. The mechanical deformation of cells appears to
cause an increase in cell proliferation, protein synthesis, and
extracellular matrix production.30
Vacuum-assisted wound closure has been used in a variety
of clinical circumstances for which free tissue transfer is
often indicated such as degloving injuries,31 and lower
extremity injuries with exposed bone.32 The vacuum wound
dressing decreases the need for free tissue transfer. This is
also true for children.33 It is an important alternative to
reconstructive microsurgery. The primary disadvantages are
possible injury of critical structures that form a part of the
wound and the additional time required to achieve wound
closure. Just as in each clinical decision faced following free
flap failure, the advantages of vacuum assisted wound
closure must be weighed against these disadvantages in
selecting the most appropriate treatment for the patient.
SECOND FREE FLAP: PEARLS FROM THE
FIRST FREE FLAP FAILURE
Although most of these precautions are intuitively present
for all free flaps (whether they are first failures or other­
wise), special attention must be given to each of these factors
in a second attempt. Again, latent factors of failure lurk also
at second attempts.
SYSTEM-BASED PRACTICE
If the RCA indicates that the causes of the first failure are
avoidable and the goals of reconstruction are such that
competence, and prevention of an orocutaneous fistula. In
some cases, a portion of the flap survives (e.g., necrosis of
only the skin component of a fibula osteocutaneous free
flap) and a repeat reconstruction has less extensive require­
ments than the original. Often, it is appropriate to consider
contralateral harvest of the same type of flap used in the
original surgery.
SELECTED LIST OF MICROSURGICAL AND
NON-MICROSURGICAL OPTIONS
A vast array of flap choices being available for the “second”
surgery, the decision to use a free flap or a pedicled flap,
OR to use a non-surgical option altogether is made on
factors defined above. A cornucopia of options exist in each
of the categories. At multiple points in the decision-making
process, a non-microsurgical option may emerge as the most
sensible option. A comprehensive list of options based
on regional requirements is provided (see also chapter 3
and figure 3.1). Surgical details of technique and operative
details are described elsewhere in this book. If the causes of
free flap failure are deemed irreversible, a non-microsurgical
option is necessary.27 If the benefits of adopting less ambi­
tious goals of reconstruction outweigh the risks of attempt­
ing a second free flap, then a non-microsurgical option
is indicated. If no suitable donor tissue or recipient vessels
are available, then non-microsurgical solutions should
be sought. Finally, the patient may simply elect to have a
less complicated surgery. As seen in Figure 30.3, a non-
microsurgical option is sufficient to deliver the results
needed in the face of a flap failure.
Non-microsurgical options consist of traditional methods
of reconstructive surgery – secondary wound closure, skin
grafting, and local and regional tissue flaps. The most
important non-traditional alternative is the vacuum-assisted
wound dressing.28 Developed in 1997 by Morykwas and
Argenta,29 it is commercially available as the vacuum assisted
closure (V.A.C.™) system (KCI Inc., San Antonio, TX). It
consists of a polyurethane foam sponge, an occlusive plastic
wound cover, a suction pump, and a fluid collection device.
The sponge has a pore size ranging from 400 µm to 600 µm
in diameter. It is cut to fit precisely over the open areas after
thorough wound debridement. The wound and sponge are
sealed with an adhesive drape and suction is delivered at
125 mmHg via a combined suction pump and collection
Figure 30.3  (A) Preoperative view. Patient scheduled for bilateral mastectomy and bilateral DIEP flaps. (B) Postoperative flap failure on right
side. (C) Postoperative following salvage reconstruction with right sided latissimus flap and implant.
A
B
C

362
PART 3 — RECONSTRUCTION
trauma). Parsimony of suture placement around the vessel
circumference assumes even greater importance. After com­
pleting the anastomosis and confirming good flow, the flap
should be allowed to perfuse for a period of time (approxi­
mately 20 min) before manipulating the tissues. This allows
the platelets coating the injured surface to stabilize and
become unable to recruit additional platelets if the blood
flow is transiently reduced as the flap is manipulated during
inset and wound closure. Check perfusion frequently during
inset to ensure continued flow. The surgeon and patient
should not leave the operating room unless there is clear
and convincing evidence of reliable flow.
POSTOPERATIVE MANAGEMENT
The flap is particularly vulnerable during emergence from
anesthesia. Difficult emergence associated with agitation,
coughing, shivering, the Valsalva maneuver, or excessive
movement can cause hematoma formation, displacement of
the pedicle, or complete disruption of the microvascular
anastomosis. If this may have contributed to flap loss, then
plans should be made to leave the patient intubated,
sedated, and paralyzed for the initial 24 h following repeat
surgery. Attention should also be directed to carefully posi­
tioning the patient to prevent pedicle compression or hema­
toma formation, especially flaps located on the head and
revascularized from cervical vessels, where head movements
affect the orientation of the pedicle. The head should be
maintained in a neutral position without a pillow. Sand bags
may be placed on either side of the head to limit rotation
of the neck. For extremity reconstruction, the affected limb
must be kept elevated to reduce soft-tissue swelling and
lower venous pressure. Splinting helps immobilize the
extremity, but circumferential dressings must be avoided
near the flap pedicle.
USE OF ADJUNCTIVE TREATMENTS
These issues play a vital role in avoiding systemic causes of
flap failure. Apart from the common culprits that affect
hypovolemia, using adjuncts to help boost circulation must
also be strongly considered. For simplicity, they have been
subdivided into the following groups. Be aware though that
each of these management methods needs to be nuanced
since if they are used injudiciously they can adversely affect
flap survival.
POSTOPERATIVE PAIN CONTROL
After surgery there is a surge in catecholamines and pro­
thrombotic mediators resulting in vasoconstriction and a
relative hypercoagulable state. In addition, a patient who is
uncomfortable can be restless and agitated, moving about
in bed and increasing the risk of pedicle compromise. Mul­
timodal analgesia (i.e., opioid analgesic agents combined
with nonsteroidal anti-inflammatory drugs, regional blocks,
local infiltration, etc.) attenuates this stress response.34
Controversy exists about the safety of nonsteroidal anti-
inflammatory drugs (e.g., ketorolac, diclofenac, ketopro­
fen) after major surgery because of concerns about the
possibility of increased bleeding. One prospective, random­
ized multicenter trial involving more than 11,000 patients
demonstrated that ketorolac (Toradol; Roche Laboratories,
Nutley, NJ) was an effective adjunct in postoperative pain
non-microsurgical options pose extreme disadvantages,
then a repeat free tissue transfer may be planned. At this
point, it is important for the surgeon to be humble and
honest regarding whether it might be in the patient’s best
interest to consult with a colleague or actually refer to a
center specializing in reconstructive microsurgery. This is
an essential ACGME-core competence. Optimal technique
and surgical judgment might be available with more expe­
rienced surgeons, and improved postoperative care might
be possible in a high-volume center.
Pearl
We practice within a highly interdependent “system”
and making a referral is not a sign of weakness but
rather an indication of confident and sound clinical
judgment.
PERIOPERATIVE MANAGEMENT
Several key factors that determine success originate in the
operating room. Dealt with at this stage, one can avoid
repeat latent errors.
• Seek the help of the anesthesiologists in maintain­
ing hydration, patient-temperature, room temperature,
avoiding pressors and maintaining optimal urine output.
• Avoid patient positioning that may cause pedicle
compression.
• Secure drainage catheters to avoid direct suction on the
pedicle.
• Position external devices such as intravenous fluid lines,
oxygen masks, wire leads, arterial lines, and drainage
catheters so that they do not compress, or cause traction
on the pedicle.
Special attention is required when moving the patient
from the operating table. Soft tissue swelling or hematomas
may squeeze the pedicle against an adjacent non-yielding
structure made of bone, cartilage, nerve, or fibrous tissues.
Passing the pedicle through a subcutaneous tunnel is par­
ticularly hazardous. Rather than creating a closed tunnel, it
is usually best to open the overlying skin and position the
pedicle under direct vision. If this is not preferred due to
concerns about surface scarring, then extreme care must be
taken to ensure that the tunnel is of adequate size, hemo­
stasis is secure, and the pedicle is not twisted or kinked
inside of it. Thrombosis due to mechanical compression
from many of these causes can often be confirmed at the
time of re-exploration.
MICROSURGICAL TECHNIQUE
Most flap losses are directly related to surgical technique.
As discussed in previous chapters, proper technique mini­
mizes vessel injury and resultant platelet aggregation at the
microanastomosis. The principles are well established. In a
setting of a second free flap, certain salient points need
special attention. Specifically, these include an even gentler
handing of the tissues at the recipient site (due to postop­
erative changes, these tissues are much more prone to

CHAPTER 30 — Reconstructive Options Following Flap Failure
363
of 100 mg completely suppresses thromboxane A2, a prosta­
glandin that promotes platelet aggregation. It is known
to prevent thrombosis in peripheral vascular surgery and
digit replantation but the benefit in routine free tissue
transfer has not been documented. Dextran 40 is the low-
molecular-weight (40 000) version of a polysaccharide that
inhibits clotting by multiple mechanisms.44 It may be admin­
istered as a continuous infusion (10%, 25 mL/h). Dextran
40 has been observed to cause respiratory distress and ana­
phylaxis,45 however, and an initial test dose is advisable prior
to infusion. Heparin prevents organized clot formation after
platelets begin to accumulate, but it is associated with a high
rate of hematoma formation.46 Animal studies have sug­
gested that low-molecular-weight heparin (LMWH) might
confer benefit without increasing complications,47 but this
has not been demonstrated clinically.
ANXIOLYTICS
The patient that undergoes a second free flap immediately
after a first failed one, is understandably anxious – and
requires special attention to allay the fears of a second
failure. This may sound unimportant but the role of intrin­
sic stress, periods of hypertension caused by uncontrolled
anxiety, and the effect of psychosocial factors on local cir­
culation is best dealt with through prevention. Judicious use
of anxiolytics and use of support systems to allay the patient’s
fears is important to the overall success.
POSTOPERATIVE MONITORING
Following one free flap failure, it is essential to regroup the
team on closer monitoring – to recognize the signs of
impaired perfusion based on clinical signs such as color,
temperature, turgor, bleeding, and capillary refill time. In
addition, it is helpful to use devices designed to assist evalu­
ation of flap perfusion. These are most beneficial for flaps
that are difficult to assess by the clinical signs described
above. Percutaneous Doppler ultrasound is the most com­
monly used aid. Other useful devices include continuous
tissue oxygen monitors,48 photoplethysmography devices,49
laser Doppler flowmeters,50 and implanted pulsed Doppler
ultrasound probes.51,52 The most widely used of these spe­
cially designed devices is the implantable ultrasound probe.
This device consists of a tiny (1 mm diameter) Doppler
crystal that is implanted at the time of surgery immediately
adjacent to the flap pedicle. It transmits a pulse of sound at
frequency of 20 MHz and then receives the sound waves
reflected from the formed elements circulating in the blood
stream through the pedicle. With this or any other special­
ized device used for flap monitoring, it is important for the
surgeon to ensure that the staff immediately responsible for
patient care in the postoperative period, understand how to
properly interpret information provided by the machine, as
well as how to troubleshoot possible problems to avoid false-
positive findings. Splints, or external fixators may be useful
to prevent flap failure by preventing pressure.53
HYPERBARIC OXYGEN
Hyperbaric oxygen has been used to improve ischemic
wounds before skin grafting and to support ischemic flaps.
Although there are a significant amount of animal data sup­
porting the application of hyperbaric oxygen for grafts and
flaps, there is very little clinical information, other than case
control and was associated with approximately 1% inci­
dence of surgical site bleeding complications.35 The risk of
adverse effects can be reduced by minimizing the dosage,
delaying administration until arrival in the post-anesthesia
care unit, limiting the length of therapy to fewer than 5 days,
and considering the use of other agents in patients with
particular risk of bleeding complications (e.g., elderly
adults).36 The benefits of using these agents must be weighed
against the risks of high-dosage narcotic drugs.
POSTOPERATIVE FLUID MANAGEMENT
Although unlikely to be an isolated cause of free flap failure,
good hemodynamic support and postoperative fluid man­
agement is important for optimizing the chances of success.37
Perfusion requirements in the surgical flap after transfer are
perhaps 30% greater than beforehand,38 making postopera­
tive hypovolemia a potential threat, despite being appar­
ently well tolerated by the patient. Mild hypervolemia may
be advantageous to flap perfusion because of increased
cardiac output with reflex peripheral vasodilatation.39 A
hematocrit value of approximately 30–35% is suitable
because the relationship between oxygen-carrying capacity
and blood viscosity is ideal in this range.40
POSTOPERATIVE VASOACTIVE DRUG USE
Vasoactive drugs must be used judiciously because adverse
effects on flap perfusion can occur independently from
systemic blood pressure. Systemic vasodilators (e.g., sodium
nitroprusside) may reduce free flap blood flow despite
maintenance of cardiac output. Alpha-adrenergic drugs
(e.g., phenylephrine) may cause decreased flap blood flow
in high doses but may not adversely affect skin or muscle
flaps if administered systemically in small doses to tran­
siently support blood pressure. Dopamine administered in
doses sufficient to support renal perfusion or increase
cardiac contractility is not detrimental to the flap. Loop
diuretics (e.g., furosemide) should be used only in cases
with evidence of congestive heart failure. They can cause
transient intravascular volume depletion, which can have an
adverse effect on blood flow through the venous microvas­
cular anastomosis, particularly in the head and neck.
Leeches are an adjunct therapy in situations where there is
good arterial inflow and the venous outflow is impeded.41
Not only can transient volume depletion promote venous
thrombosis, but also compensatory increase in circulating
catecholamines may have adverse effects. If aggressive diure­
sis is indicated, it should be guided by direct hemodynamic
monitoring. These hemodynamic factors are unlikely to
independently cause a flap failure, but they affect the
balance of factors acting on flap success and could contrib­
ute to flap loss if not properly managed.
POSTOPERATIVE ANTICOAGULATION
The use of systemic anticoagulation in reconstructive micro­
vascular surgery varies widely, but most surgeons agree that
routine use is not necessary.42,43 When a second micro­
vascular flap is performed to salvage a reconstruction fol­
lowing flap failure, systemic anticoagulation is indicated if
unfavorable conditions persist that are not correctable (e.g.,
radiation tissue injury, severe atherosclerosis, etc.). If anti­
coagulation is used, the drugs of choice are aspirin, dextran
40, or heparin. Aspirin impairs platelet function, and a dose

364
PART 3 — RECONSTRUCTION
reports and series to sustain its choice over other modalities
of therapy. Apart from one study that provides clinical data
characterizing and supporting the application of hyperbaric
medicine to aid in the viability of compromised flaps in 11
patients,54 there are no studies validating its use. Multicenter
prospective clinical studies are clearly needed comparing
hyperbaric oxygen with other mechanical or pharmacologic
interventions to improve wound healing for grafting or to
support flap survival.55
COMMUNICATION AND LEADERSHIP
Critical to our role as surgeons at all times, effective com­
munication becomes very important in the event of a free-
flap failure. At three distinct times during the patient’s care,
clear communication is critical: first, when the flap has
failed prompting a frank explanation of the situation, to
both patient and the family as well as the treating team;
second, after the decision of the way forward has been
made, it needs to be communicated effectively to seek the
patient’s 100% commitment and approval; and lastly, when
in the postoperative period, the anxiety is high, as are the
expectations. Effective communication and leadership
creates the healthy relationship that is the essential compo­
nent of effective treatment.
CONCLUSIONS
In summary, managing a patient after a failed free flap
is one of the most challenging aspects of reconstructive
microsurgery. The surgeon must make thoughtful clinical
decisions, possess technical skills, and apply effective
interpersonal skills. A systematic approach with preplanned
alternatives yields the greatest chance of a successful
outcome.
Expert Commentary 
Stefan O.P. Hofer, MD, PhD, FRCSC
Free flap failure constitutes a devastating experience for the
patient as well as the surgeon. As presented, it is important
to analyze the situation and assess the factors that could
potentially have contributed to this outcome. No honor is lost
by an honest assessment in a blame-free environment, as all
involved need to learn from this experience to become
better. Fortunately, free flap failure is an extremely rare event
and proper analysis of the cause is important, as this is a rare
learning opportunity.
As a basic rule, one can assume that if a free flap failure
has occurred, the best option to fix this situation is with a
second free flap. If the situation is better managed with a
local/regional flap, skin graft, or alternative wound manage-
ment technique, then the question is whether the original
indication was correct in the first place. That said, very careful
analysis of the failure needs to be undertaken as it would be
unforgivable to fail the second time from the same cause as
the first time. In short, patient factors (blood pressure, body
temperature, pain control), recipient site vessels, flap and
vascular pedicle positioning, microsurgical technique, tight-
ness of flap inset and postoperative swelling, external com-
pression, and local infection, need to be taken into account.
These should all be factors that can be controlled for success,
and a second free flap would seem the responsible option.
Factors that are outside our sphere of influence to some
extent are mostly related to blood-clotting disorders. When
maximal control of these clotting disorders is performed and
these still result in flap failure then alternatives for free flap
reconstruction should be seriously considered.
With the above in mind, one should also keep in focus what
type of condition was treated by the free flap reconstruction.
There are different types of urgency for different reconstruc-
tion. In situations where, e.g., exposed large vessels, open
dura, or open connection between the oral cavity and neck
are present, an immediate and adequate reconstruction will
be of greater urgency than in, e.g., a situation where exposed
bone is covered, which could be temporarily bridged with a
wound dressing or in a delayed breast reconstruction, which
could be reattempted when the situation has settled down
again. In all of these cases, however, if a decision for a
second free flap is made and the patient is well enough and
agreeable, this should be attempted within the first 5–10
days to prevent greater risk for infection complications.

CHAPTER 30 — Reconstructive Options Following Flap Failure
365
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examples 1 and 2 online at
.inkling.com
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CHAPTER 30 — Reconstructive Options Following Flap Failure 365.e1
Case illustration of failed free flap with repeat microvascular
procedure: a middle-aged man with advanced thyroid cancer
requiring total laryngopharyngectomy including anterior cervi-
cal skin. He underwent immediate reconstruction with a free
jejunal transfer, pectoralis major musculocutaneous flap, and
split-thickness skin graft to restore the cervical esophagus and
anterior cervical skin (Fig. 30.4).
CASE 30.1  Failed Free Flap with Repeat Microvascular Procedure
Figure 30.4  (A) Appearance of externalized segment of jejunum used for flap perfusion monitoring that demonstrates venous congestion.
The flap was not salvaged due to delayed diagnosis of pedicle thrombosis, a reversible cause of flap loss. Suitable donor tissue and
recipient vessels were available, and the patient was willing to undergo a repeat microvascular procedure. (B) View of well-perfused
monitoring segment after repeat free jejunal transfer. (C) Patient appearance 6 months following successful reconstruction with repeat
microvascular procedure.
B
A
C
Case illustration of failed free flap without repeat microvascular procedure (Fig. 30.5).
CASE 30.2  Failed Free Flap without Repeat Microvascular Procedure
Figure 30.5  (A) Preoperative appearance of a 52-year-old woman who underwent bilateral breast reconstruction with deep inferior epi­
gastric artery perforator (DIEP) flaps revascularized from the internal mammary vessels. (B) Intraoperative view of one DIEP flap. (C)
Appearance of right DIEP flap with irreversible pedicle thrombosis occurring on postoperative day 9. Due to uncertainty of a reliable donor
site and recipient vessels, as well as patient preference, a repeat microvascular procedure was not performed. (D) At 2 months later, a
reconstruction was performed using a latissimus dorsi musculocutaneous rotation flap and breast implant. (E) Appearance 5 months after
reconstruction.
A
C
D
E
B

366
PART 3 — RECONSTRUCTION
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54. Larson JV, Steensma EA, Flikkema RM, et al. The application of
hyperbaric oxygen therapy in the management of compromised
flaps. Undersea Hyperb Med 2013;40(6):499–504.
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Reconstr Surg 2006;117(Suppl. 7):175S–192S.

367
Local Flaps in the
Head and Neck: Forehead,
FAMM, Submental,
Nasolabial and
Cervicofacial Flaps
Robert L. Walton  |  Thomas Willson  |  Elliot Hirsch
31 
Figure 31.1  Forehead flap.
Levator labii
superioris
Nasalis
Corrugator
supercilli
Orbicularis oris
Depressor anguli oris
Risorius
Masseter
Zygomaticus
minor
Frontalis
(beneath fascia)
Supratrochlear
artery and nerve
Temporalis
Orbicularis
oculi
Supraorbital
artery and
nerve
Depressor labii
inferioris
Zygomaticus
major
Levator labii
superioris
alaeque nasi
Buccinator
Procerus
Levator anguli oris
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION A  —  LOCAL AND FREE FLAPS IN THE HEAD AND NECK

368
PART 4 — CONVENTIONAL WORKHORSE FLAPS
and versatile vascular supply to the forehead (see Figs 10.4
and 10.5).5,6 These vessels course superficial to the muscle
layer in the subcutaneous fat. The robust vascularity of this
region provides for a variety of forehead flap designs. The
ancient Indian method of nasal reconstruction utilized a
central or median forehead flap based on the vascular
plexus created by these vessels.1 While still utilized, the
median forehead flap design limits pedicle length and has
a less reliable vascular circulation as it lacks an axial vessel.
The paramedian forehead flap is an axial flap that incor­
porates a vertical arterial branch of the supratrochlear
artery and is the most reliable method of transferring fore­
head tissue for nasal reconstruction.1,3
ARTERIAL AND VENOUS SUPPLY OF THE FLAP
ARTERIAL SUPPLY (Figs 10.4 and 10.5)
Dominant:  supratrochlear artery
Length: variable 2–4 cm
Diameter: 0.2–1.5 mm
The blood supply to the paramedian forehead flap is
primarily via the axial supratrochlear artery.5,6 After exiting
its foramen (see Fig. 10.1) the supratrochlear vessel courses
over the periosteum at the supraorbital rim for a short dis­
tance (1 cm) and then divides into deep and superficial
branches. The deep branch terminates in several small
branches that extend 2–3 cm over the periosteum. The
superficial branch continues in a cephalad direction, pierces
the frontalis muscle and courses in the subcutaneous fat
plane, where it terminates in multiple small branches that
anastomose with the subdermal plexus of the mid- and supe­
rior forehead.
Other contributing arteries include the dorsal nasal
artery, an extension of the angular artery, and the supraor­
bital artery. These vessels form a plexus that intercommuni­
cates in the superficial periosteal plane at the level of the
orbital rim and nasal glabella. Axial extensions of this plexus
perforate the frontalis muscle and course in the subcutane­
ous fat joining a rich subdermal plexus in the upper fore­
head and scalp. It has been shown that optimal incorporation
of the vessels supplying the paramedian forehead flap
should include elevation of the periosteum 2–3 cm cepha­
lad to the base of the flap, and preserving 7 mm of tissue
above the supraorbital rim as a zone of safety to optimize
inclusion of branches from the supraorbital plexus.6 Experi­
ence has shown that these landmarks of elevation can be
exceeded if additional flap length is required. As the flap
dissection proceeds proximally, however, and the periosteal
layer is elevated with a narrowed overlying skin pedicle, the
communicating branches from the supraorbital and angular
systems may be divided, thereby stifling any benefit of
improved perfusion provided by the superior orbital plexus.
VENOUS DRAINAGE (See Figs 10.4 and 10.5B)
Venous drainage of the forehead flap parallels its arterial
inflow with communications between the random dermal
plexus of the upper forehead, to the axial supratrochlear
system with anastomotic connections to the periorbital
plexus, as described above, and the angular system.
INTRODUCTION
Over the years, numerous local flaps have been utilized for
closure of facial defects. Owing to the robust blood supply
of the facial soft tissues, many local flaps have been based
on the dermal and subdermal capillary circulation and
simply represent the geometric repositioning of the skin
and soft tissues. Other flaps, such as the paramedian fore­
head flap and the nasolabial flap, are based on known vas­
cular systems of the face and have evolved through improved
understanding of these systems, as well as refinements in
flap design that optimize vascularity. The facial artery mus­
culomucosal (FAMM) and submental flaps are direct
descendants of this recent renaissance in our understand­
ing of the vascular systems of the face.
FOREHEAD FLAP
INTRODUCTION
The forehead flap is one of the first flaps used and
reported in surgery of the face. While its origins are
unclear, the flap was likely used before the birth of Christ.1
First known as the median forehead or Indian flap, it has
been performed in India since 1440, and the first English
descriptions of the flap first appeared in the Madras Gazette
in 1793, and a year later in the Gentleman’s Magazine of
London. Two cases of nasal reconstruction using the Indian
forehead flap were reported in 1816, by the English
surgeon, Carpue.1 In the United States, Kazanjian first pro­
moted the median forehead flap, the design of which
included both supratrochlear arteries.2 Millard demon­
strated that the mid-forehead flap could survive on just
one supratrochlear artery, which greatly facilitated its
transfer to the nasal site.3 Subsequent refinements in the
design and execution of the paramedian forehead flap
were described by Burget and Menick.4 The paramedian
forehead flap has evolved as the primary flap for recon­
struction of the external cover of the nose due to its
texture and near perfect color match to nasal skin. Its
robust vascularity, ability to accommodate a wide variety of
flap designs, and a very forgiving donor defect make the
forehead flap a major workhorse in nasal reconstruction
primarily, and for the reconstruction of a variety of adja­
cent periorbital and cheek defects.1
FLAP ANATOMY (Fig. 31.2 and Figs 10.1, 10.4
and 10.5)
The forehead flap is a versatile flap for reconstruction of
the nose and the nasal glabellar region (Fig. 31.2). It is
reliable, well-perfused, easily harvested, and has an accept­
able donor site. The forehead flap is composed of the skin
and subcutaneous tissues of the forehead, including the
subcutaneous fat, variable portions of the frontalis, corru­
gator, and procerus muscles, and a thin fascia/fibroareolar
layer contiguous with the scalp galea that lies directly deep
to the muscle layer. An interconnecting arcade of the
supraorbital, supratrochlear, infratrochlear, superficial
temporal, dorsal nasal, and angular vessels provide a rich

CHAPTER 31 — LOCAL FLAPS IN THE HEAD AND NECK
369
FLAP DESIGN
ANATOMIC LANDMARKS (Case 31.1, Fig. 31.3)
Design of the forehead flap is based on a template of the
defect that is centered over the supratrochlear artery.1,4
Using a handheld Doppler, the course of the supratrochlear
artery is identified and marked from its origin from the
supratrochlear foramen on the medial orbital rim to the
mid-forehead. A foil template of the defect is made. Foil
derived from suture packet is ideal for this purpose, as it
has a shiny side and a color side that can be helpful in
FLAP INNERVATION (Figs 31.2, 10.11)
Sensibility in the central forehead is provided via the supra­
trochlear and supraorbital nerves. Branches of these nerves
may be included in the paramedian forehead flap during
its elevation, allowing for some cutaneous sensibility. Proxi­
mal flaps that are directly transferred and inset around the
nasal glabella, dorsum, or sidewall regions may retain their
sensibility. The more common distally targeted flaps, based
on a supratrochlear pedicle, lose sensibility following pedicle
division.
Figure 31.2  Nerve supply of the scalp: sensory distribution. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights
Reserved.)
Zygomaticotemporal nerve
From ophthalmic division
of trigeminal nerve (V1)
Supraorbital nerve
Supratrochlear nerve
Auriculotemporal nerve
Greater occipital
nerve (C2)
3rd occipital
nerve (C3)
Branches from
cervical plexus
Lesser occipital
nerve (C2)
Medial branches
of dorsal rami
of cervical spinal nerves
From mandibular division
of trigeminal nerve (V3)
From maxillary division
of trigeminal nerve (V2)
Occipital belly (occipitalis) of
occipitofrontalis muscle
Greater occipital nerve
(dorsal ramus of C2
spinal nerve)
Occipital artery
Posterior
auricular artery
Great auricular nerve
(cervical plexus C2, 3)
Lesser occipital nerve
(cervical plexus C2, 3)
3rd (least) occipital nerve
(dorsal ramus of C3
spinal nerve)
Epicranial aponeurosis
(galea aponeurotica)
Greater occipital
nerve (dorsal ramus
of C2 spinal nerve)
Occipital artery
Posterior arch of
atlas (C1 vertebra)
Suboccipital nerve
(dorsal ramus of C1
spinal nerve)
3rd (least) occipital nerve
(dorsal ramus of C3
spinal nerve)

Figure 31.3  (A) Photograph showing the skin lesion prior to resection. (B) Wide composite surgical excision of the ala was required.
Following histologic confirmation of tumor-free margins, reconstruction of the defect commenced. A foil template of the external cover
defect was used for the design of the forehead flap. (C) In this case, the lining defect was reconstructed using a nasal septal mucosal
hinge flap and a local vestibular flap. (D) The alar defect was supported using conchal cartilage grafts for the rim and sidewall. Secured
with fine polypropylene sutures. (E) Design of the forehead flap. Doppler assessment of the ipsilateral supratrochlear system is made for
correct positioning of the base of the pedicle. The foil template of the alar defect is included in the flap design. In this case, the entire
aesthetic alar subunit of the nose will be reconstructed. As a general rule, if the defect is 50% of an aesthetic subunit or greater, the entire
unit should be excised and reconstructed. In designing the flap, care is taken to ensure that the distal end of the flap can easily reach the
defect without tension. Careful measurements are made of the flap length from its tip to its base and then transposed from the anticipated
flap pivot point to the most distal aspect of the defect. (F–H) The flap is shown following its inset into the alar defect. Modest debulking
of the distal 10–15 mm of the flap can be performed at the initial inset to facilitate repair of its distal edge with the nasal lining. In these
cases the depth of the debulking should not exceed beyond the level of the frontalis muscle with care taken to preserve the longitudinal
veins coursing in the superficial subcutaneous tissue. The undersurface of the flap pedicle is lined with a split-skin graft to minimize serum
oozing and to simplify wound care at home. The lower forehead donor defect is closed primarily in layers. The upper portion of the fore­
head donor defect that cannot be closed primarily is dressed with a petrolatum-impregnated dressing (to prevent desiccation) and allowed
to heal by secondary intent. (I–K) The patient is shown 1 year following completion of the reconstruction. A forehead flap debulking pro­
cedure was performed at 8 weeks following the initial flap elevation and inset. The flap pedicle was divided 6 weeks later.
A
B
C
D
E
F
G
H
I
J
K
A 55-year-old woman presented with a large invasive basal cell
carcinoma of the left nasal ala. The patient underwent a wide
composite resection and a staged reconstruction with a forehead
flap and cartilage grafts.
CASE 31.1  Composite Ala Defect Reconstructed with Local Mucosal Flaps, Cartilage
Grafts, and a Forehead Flap

CHAPTER 31 — LOCAL FLAPS IN THE HEAD AND NECK
371
the external cover template. The lining extension is made
larger than needed to accommodate a relaxed folding –
about 4–5 mm during inset to avoid compromising the
dermal perfusion of the distal flap elements. Utilizing this
approach, the flap is folded on itself and inset. Flap debulk­
ing and placement of cartilage grafts to achieve the desired
contour and dimensions of the reconstruction are per­
formed in a secondary procedure.
GENERAL THOUGHTS ABOUT FLAP DESIGN
The paramedian forehead flap is quite reliable with a
robust vascular supply. The key to success with the flap is
axial orientation of the long axis of the flap template
directly overlying the course of the superficial branch of
the supratrochlear artery. In isolated patients the supra­
trochlear system may be very small or undetectable via
Doppler. In these cases the opposite side should be exam­
ined, and if the supratrochlear system is identified, the
flap should be based on this side. If neither side exhibits
an identifiable supratrochlear artery, delay of the template
over the anticipated course of the supratrochlear system
may be required. Following flap design, an incision is
made around the flap perimeter to just above the perios­
teal layer and then closed with fine sutures. In 14–21 days
the flap is elevated and examined for adequacy of perfu­
sion. If mottling or hypoperfusion is identified, further
delay is warranted.
Flaps based on the supratrochlear system may have a
variety of configurations and sizes depending on the recon­
structive requirements. As demonstrated by Reece et al.,
random dermal extensions beyond the linear axial course
of the supratrochlear artery can be included to avoid the
hair-bearing scalp.6
FLAP DIMENSIONS
Flaps measuring 8–9 cm in width and encompassing the
length of the forehead can usually be elevated primarily
without delay. Additionally, random extensions oriented
obliquely beyond the axial line of the supratrochlear system
can be safely included in flap design.6 Extensions of the flap
superiorly into the frontal hairline beyond 1–1.5 cm are
unpredictable with regards to reliability and should be
delayed.
TECHNIQUE OF FLAP HARVEST (Case 31.1, Fig. 31.3)
Primary elevation of the flap is performed incorporating
the skin, subcutaneous, frontalis muscle layer, and the sub­
muscular fibroareolar layers of the forehead. Dissection is
begun from the superior forehead to the base of the
pedicle. Following incision of the flap perimeter, dissection
is carefully performed just above the periosteal layer. It is
important to not elevate the periosteal layer of the superior
forehead to avoid frontal bone exposure and delayed
healing, and epithelialization of the donor defect. As the
dissection proceeds to within 2–3 cm from the base of the
flap, the periosteum is included with the flap base to
include the periosteal branch of the supratrochlear artery.
Flap perfusion is further optimized by limiting the skin
incision to 7 mm above the supraorbital rim so as to
demarcating the “skin” and “subcutaneous” sides of the flap
– a simple way to ensure the accuracy of flap design and
minimize the potential for inadvertent reversal of the
pattern and the harvest of a backward flap. An ipsilateral
paramedian forehead flap permits the maximum arc of
rotation. A left-sided flap should rotate counter clockwise,
and a right-sided flap, clockwise. This orientation will
provide the shortest distance between the flap pivot point
and the nasal defect and place the skin of the forehead flap
facing the ipsilateral eye, as opposed to the raw surface
underlying the flap, which is preferable in terms of patient
comfort. The arc of rotation of the flap should be carefully
measured from the vascular base of the flap, which serves
as the pivot point. This should be placed at the nasal root
of the medial brow. Palpation of the bony landmarks of the
orbit can facilitate the location of the proper pivot point.
The flap pivot point can be extended inferiorly to gain
further reach if periosteal release and meticulous dissection
of the vascular pedicle are carried out in the subperiosteal
plane. This should be performed under loupe dissection for
proper identification and preservation of the supratroch­
lear vessels. It is important to accurately assess the true flap
pedicle length. An overly tight inset can compromise the
vascularity of the distal forehead flap or compromise the
integrity of the reconstruction by elevation or distortion of
the underlying framework and lining. Redundancy of the
flap pedicle may be troublesome to the patient in terms of
interference with the nasal visual field.
Because of the position or size of the forehead flap in
relation to the frontal hairline, hair-bearing scalp tissue may
need to be included as part of the flap. This issue must be
carefully addressed and discussed preoperatively and par­
ticularly with those patients having a relatively short fore­
head, and/or those having a distal nasal defect such as one
involving the columella. The hair can be depilated during
flap harvest in a non-smoking patient by thinning the distal
1–1.5 cm of the flap, or it can be removed at a later juncture.
If there is any doubt as to the integrity of the flap’s vascular
supply, it is best to delay thinning/depilation for a subse­
quent revision.
An alternative to extending the flap into the frontal hair­
line has been proposed by Reece et al.6 This modified
version of the paramedian forehead flap incorporates the
vertical axis of the supratrochlear system and an oblique,
hairless forehead extension that is based on the subdermal
plexus supplied via the terminal branches of the supratroch­
lear system. This flap also includes perforators from the
deep periosteal branch of the supratrochlear artery, and the
three-vessel flow supported through the superior orbital
plexus.
The paramedian forehead flap should be designed with
a base of 1.2–1.5 cm in width at the pivot point directly
overlying the supratrochlear vessels. A wider flap base is at
risk for compressing the feeding vessels when the flap is
rotated.2,3
In nasal reconstruction, a lining component of the fore­
head flap can be included in the design for the external
cover.7 The flap template can be extended to include por­
tions of the vestibular lining and/or columella. This tech­
nique has utility provided that the lining defect is not
excessive. In these situations, the dimensions of the missing
lining are added as a distal extension to the alar margin of

372
PART 4 — CONVENTIONAL WORKHORSE FLAPS
established. At this point, the wound is managed with
topical Preparation H or A&D ointment and a Telfa pad
until epithelization is complete. Moisturizers are then
applied thereafter. Avoid topical antimicrobials containing
silver as the silver may leach within the substrate of the
migrating epithelium leading to undesirable pigmentation
of the wound.
Drains are generally not required for the forehead under­
mining and closure. A benefit of allowing the forehead
donor site to heal by secondary intent is complementary
pigmentation of the epithelized defect with excellent color
match to the surrounding forehead skin. Following flap
division, the proximal pedicle stump is re-inset into the base
of the donor defect as an inverted “V.”
For forehead donor sites that result in unacceptable scar­
ring, the adjacent normal forehead skin may be expanded
to replace the scar. Alternatively, epidermal overgrafting of
the scar can be performed using split scalp grafts resulting
in substantial improvement in color.8
FLAP USAGE
The forehead flap is indicated for all varieties of nasal exter­
nal cover and limited nasal vestibular defects ranging from
isolated alar or tip defects to total and subtotal nasal exter­
nal cover defects. In rare situations, two forehead flaps may
be utilized to provide for both lining and external cover.
Large lining defects involving the vestibule and middle
nasal vault are best managed with remote free flaps such as
the radial forearm flap, reserving use of the forehead flap
for external cover.8
The forehead flap may also be utilized for a variety of
periorbital defects resulting from cancer ablation or trauma.
The design of the flap can be quite elaborate as long as its
major axis is centered over the course of the supratrochlear
artery. Flap design in this setting is critical to ensure that
the important distal part of the flap reaches its intended
target without tension or kinking of the pedicle. Designing
the flap template 2–3 mm larger than the defect provides
for a margin of safety to ensure sufficient dimensions for
closure without tension.4
POSTOPERATIVE CARE AND EXPECTED
OUTCOMES
In most cases the forehead flap is transplanted to its target
defect as a pedicled flap. As noted above, in these instances
the undersurface of the pedicle is closed with a split-
thickness skin graft to facilitate wound management. The
skin graft suture line is dressed with a light application of
antibiotic ointment. The inset portion of the forehead flap
is similarly left open and dressed with a light application of
antibiotic ointment, applied twice daily following suture line
cleansing. Skin sutures are removed at 5–6 days and the
wound is then reinforced with fine skin tapes for, an addi­
tional week.
The robust blood supply of the forehead flap allows for
excellent healing in most circumstances. In smokers, in
patients with systemic vascular disease, or in patients having
scarred foreheads in which the axial or random aspects of
the forehead blood supply have been damaged, flap isch­
emia and necrosis can complicate the anticipated outcome.
optimize inclusion of vascular contributions from the
supraorbital plexus.
The distal 15 mm of the flap can be thinned of its mus­
cular and subcutaneous layers in the primary setting pro­
vided that the longitudinal subcutaneous veins, coursing in
the superficial subcutaneous layer just below the dermis, are
preserved. This facilitates flap insetting in the tip, columella
and alar rim. For folded forehead flaps, thinning is delayed
until the second procedure in which the lining element is
separated from the external cover. At this time, the lining
can be aggressively thinned to its dermis.
The flap is inset in layers with fine monofilament absorb­
able sutures for the deep muscular layer and percutaneous
polypropylene sutures for the skin. Where the flap has been
thinned prior to inset, a simple percutaneous suture closure
is employed. If excessive tension is encountered during
inset of the flap, this can be partially relieved by insetting
the muscle layer of the forehead flap to the skin or mucosal
layer of the target defect. The resulting subcutaneous “gap”
at the site of inset will eventually heal by secondary intent
with local wound management to prevent drying. In these
cases, liberal amounts of ointment are applied to the open
wound areas during healing.
After the flap is inset into its target defect, the undersur­
face of the flap pedicle is temporarily closed with a split-
thickness skin graft. This approach is favored over wound
dressings as the skin graft will “take” to the undersurface of
the flap pedicle, stifling the messy blood and serum ooze
that occurs postoperatively. The skin graft is placed without
tension and trimmed to match the defect. It is inset with 5-0
chromic catgut suture.
DONOR SITE CLOSURE AND MANAGEMENT
Closure of the donor defect may be primary, with a skin
graft, or by allowing healing via secondary intent. Each
method has certain advantages. Primary closure of the
donor defect is generally reserved for smaller flaps <2.5 cm
in width. Minimal submuscular undermining is required to
close with minimal tension. Skin graft closure is preferred
for flaps that are excessively wide, especially at the base,
where primary closure will distort the position of the medial
brows resulting in an unaesthetic, unnatural facial/perior­
bital appearance. The graft is usually removed and replaced
by re-insetting the proximal flap pedicle into its original
defect following forehead flap division and inset.
Flaps having a narrow (1.5 cm) base but with a wider
superior distal defect on the forehead, can be managed by
primary closure of the proximal defect and allowing the
superior or distal defect in the mid- and upper forehead to
heal by secondary intent. In this sitting, wide submuscular
undermining of the forehead is performed to gain suffi­
cient mobilization for closure of the lower 4–5 cm of fore­
head with minimal tension. This also provides for partial
closure of the mid- and upper forehead defect minimizing
the size of the remaining wound that will eventually heal by
secondary intent. It is important to not allow the exposed
periosteum to dry, as this will result in necrosis of the peri­
osteum and eventual exposure of the frontal bone, leading
to delayed healing and possibly the need for additional
surgical intervention. We have found it helpful to cover the
exposed periosteum with petrolatum-impregnated gauze
until epithelization commences and a granulation base is

CHAPTER 31 — LOCAL FLAPS IN THE HEAD AND NECK
373
off the inferior labial artery at the inferior border of the
buccinator muscle along with the sublabial artery (labio­
mental artery), approximately 70% of the time. The facial
artery ultimately comes to a point 1–2 cm lateral to the
oral commissure, where it gives off the superior labial
artery as well as 3–5 branches to the buccinator muscle
and a small superficial branch to the zygomaticus major
muscle. From this point, the anatomy of the facial artery is
highly variable. Approximately 80–90% of the time, the
facial artery continues as the lateral nasal artery and gives
off both superior and inferior alar arteries before either
terminating as the superior alar artery or continuing as the
angular artery before terminating near the medial canthus.
The remainder of the time, the course of the facial artery
may include a separate takeoff of the angular artery after
crossing the inferior border of the mandible, septal and
inferior/superior angular arteries branching from the
superior labial artery, or a rudimentary facial artery that
gives off inferior labial artery only. Even within individuals,
there is variation between right and left sides of the face as
the facial artery branching and termination pattern is only
considered to be symmetric approximately 50% of the
time.10
Dominant:  facial artery
Length: 7–8 cm
Diameter: 1.7 mm (1–2 mm)
After crossing over the mandibular border, the diameter
of the facial artery is 2.6 mm (range 1.6–3.6 mm). It
decreases to approximately 1.7 mm over its course as it
nears the oral commissure.
VENOUS DRAINAGE OF THE FLAP (See Figs 10.4
and 10.5B)
Primary:  subdermal plexus
Venous drainage of the flap is provided by a robust venous
plexus that envelops the facial artery along its course and
communicates with the pterygoid plexus and internal maxil­
lary vein posteriorly, and the facial vein anteriorly; no dis­
crete named vein is included in the flap.9
FLAP INNERVATION
There are no sensory or motor nerves that are harvested
with the FAMM flap.
FLAP DESIGN
ANATOMIC LANDMARKS (Case 31.2, Fig. 31.4)
First, the course of the facial artery is identified by Doppler
along the buccal mucosa surface intraorally, and is marked
along its course from the retromolar trigone to the gingivo­
buccal sulcus. The entire length of the facial artery as it
traverses the buccal mucosa can be included in the flap if
necessary. The width of the flap is next determined, and can
include up to 3 cm of buccal mucosa as needed for the
reconstruction. Special care should be taken to avoid injur­
ing Stensen’s duct, which enters the mouth adjacent to the
second maxillary molar. Flap design should remain anterior
to the duct.
In these settings it is prudent to anticipate problems before­
hand so as to minimize the morbidity of delayed healing
and flap failure. If a Doppler signal cannot be detected
prior to flap elevation, if the flap appears mottled following
elevation, or has areas that appear to be poorly perfused, it
may be best to delay the flap. As well, if scar traverses a
portion of the flap, and there are no reasonable alternatives
for flap location, it is best to consider delaying the flap to
optimize its perfusion.
FAMM FLAP
INTRODUCTION
The facial artery musculomucosal flap (FAMM) is an axial
flap based on the facial artery that is very useful for cover­
age of soft tissue defects of the oropharynx and nasophar­
ynx, as well as the lip. First described by Pribaz et al. in
1992 as an evolution of the buccal mucosal flap, reports of
the FAMM flap have been widely reported in the litera­
ture.9 Indications are not limited to oncologic and trau­
matic reconstruction, as the FAMM flap is especially useful
in the management of refractory palatal fistulae following
treatment for cleft palate. The flap is harvested as a pedi­
cled flap and may not be used as a free flap, given that
venous drainage relies on a robust venous plexus rather
than a discrete, named vein. It may be superiorly or
inferiorly based, which gives it significant versatility and arc
of rotation that allows its application for a wide variety of
defects.
FLAP ANATOMY (See Figs 10.4, 10.5)
The FAMM flap is harvested intraorally and is based on the
facial artery. As the facial artery courses across the cheek, it
lies superficial to the buccinator muscle, which is the
deepest muscle of the sphincteric system of the mouth.
Deep to the buccinator muscle lies the submucosa and oral
mucosa. Near the oral commissure, the facial artery is also
deep to the lateral edge of the deep lamina of the orbicu­
laris oris muscle as well as the levator anguli oris muscle,
and may be superficial or deep to the levator labii superi­
oris muscle.
When harvesting the FAMM flap, it is important to con­
sider the course of the parotid duct. The parotid duct exits
the parotid gland and courses through the buccal fat pad
before piercing the buccinator muscle and entering the
mouth at the level of the second maxillary molar at the
parotid papilla.
ARTERIAL AND VENOUS SUPPLY OF THE FLAP
(See Figs 10.4 and 10.5)
ARTERIAL SUPPLY OF THE FLAP
Arterial supply of the FAMM flap is based on the facial
artery. After crossing over the inferior border of the man­
dible at a mean of 6.5 cm from the symphysis, the facial
artery gives off small muscular branches to the masseter
and the depressor anguli oris muscles. The facial artery
then follows a tortuous course obliquely upward and gives

374
PART 4 — CONVENTIONAL WORKHORSE FLAPS
lead to tethering of the cheek and restricted jaw movement.
If it is felt that the buccal mucosal closure is excessively tight,
a full-thickness skin graft may be utilized to close the defect.
Alternatively, triangular mucosal V-Y advancement flaps may
be utilized to ease tension on the closure. These adjunctive
procedures may be performed at a later stage as well.
FLAP DESIGNS FOR PARTICULAR TYPES OF
RECONSTRUCTIONS
The FAMM flap is either superiorly or inferiorly based. In
all cases, the flap is elevated and transposed into the target
defect. If the target defect is in continuity with the flap
donor site, direct transfer and inset is performed. If the flap
must traverse intact oral mucosa to reach its target defect,
the flap’s distal end is inset and the pedicle is divided in a
second stage 10–14 days later. This is particularly useful
when treating defects of the palate or floor of mouth that
are lingual to the alveolus. In these cases, a bite block should
be used to protect the pedicle when teeth are present.11
However, it is possible to route the flap posteriorly in the
GENERAL THOUGHTS ABOUT FLAP DESIGN
The FAMM flap is an axial flap and must follow the course
of the facial artery. The facial artery courses obliquely
through the cheek; therefore, the flap design should be
obliquely oriented as well.
The connection between the facial artery and the bucci­
nator muscle contains small communicating vessels that
provide nourishment to the overlying buccal mucosa. This
connection between the buccinator muscle and the facial
artery is somewhat tenuous, and care must be taken to
ensure that the artery and muscle do not become separated
during flap elevation and inset.
Although venous drainage from the FAMM flap via a
robust venous plexus envelope the facial artery, this plexus
arrangement is fairly efficient. The base of the flap should
be kept wide and the facial artery should not be skeleton­
ized as this may interrupt the venous outflow.
A maximal flap mucosal width of 3 cm may be used;
however, closure of these wider flap donor site defects may
This child presented with a history of bilateral cleft lip along with
a bilateral clefts of the primary palate (anterior to the incisal
foramen). The defect was reconstructed with local turnover flaps
to line the nasal aspect of the defect and a FAMM flap to resur-
face the oral lining. The patient healed well without any
complications.
CASE 31.2  Anterior Palate Defect Reconstructed with a Superiorly Based Pedicled
FAMM Flap
Figure 31.4  (A) Preoperative view showing a large fistula anterior to the incisal foramen. (B) Intraoperative view showing the nasal side
of the defect reconstructed with local turnover flaps from the palate and premaxilla. (C) Marking of the FAMM flap. The artery is Dopplered
and marked. The flap is marked around the Dopplered artery. An incision is made along the inferior aspect of the flap. The facial artery
is located first, then the flap is remarked and harvested. (D) The flap is harvested including the artery. A handheld Doppler is used to
ensure that the artery is included in the flap. (E) The FAMM flap is pedicled superiorly. (F) The FAMM flap is inset into the defect and used
to reconstruct the oral lining. This procedure was performed in one stage where an incision was made connecting the flap with the defect.
In some situations this procedure could be performed in two stages where the flap is inset and the pedicle is divided 2–3 weeks later.
(G) The patient is seen several months postoperatively and has healed without any evidence of a fistula. (Courtesy of Samir Mardini, MD.)
A
B
C
D
E
F
G
E

CHAPTER 31 — LOCAL FLAPS IN THE HEAD AND NECK
375
DONOR SITE CLOSURE AND MANAGEMENT
A two-layer closure of the donor site is typically performed
using 4-0 synthetic absorbable polyglactin or polydioxanone
suture to approximate the buccinator muscle and 4-0
chromic catgut suture to close the buccal mucosa. Postop­
eratively, the patient is placed on a puree diet for 3 weeks
and prescribed an antibacterial mouth rinse to be used post-
prandial and at bedtime.
FLAP USAGE
Indications: The FAMM flap is used for reconstructions of
the oropharynx, including the lips and vermillion, and the
nasopharynx.
When the flap is superiorly based, the arc of rotation
allows it to treat defects of the palate, upper gingivobuccal
sulcus, nasal lining, upper lip, and the orbit. When the flap
is inferiorly based, it may be used to close defects of the
floor of mouth, tonsillar region, alveolus, lower lip, and
mandibular gingivobuccal sulcus.
POSTOPERATIVE CARE AND
EXPECTED OUTCOMES
In general, patients who have undergone FAMM flaps do
not require specialized care. They may begin a liquid diet
on the day of surgery, and progress to a puree diet starting
on day 3. By 3 weeks, the patient can return to a regular
diet. When performing a lingually placed FAMM flap in a
patient with intact dentition, a bite block should be secured
in place to protect the pedicle until after pedicle division
and inset.
Owing to the proximity of the facial artery to the levator
anguli oris, the levator labii superioris and the orbicularis
oris muscles (see Figs 10.1, 10.5), some weakness in anima­
tion of the lips may result from flap harvest. While careful
elevation of the flap from its bed will minimize injury to
these muscles and their respective motor nerves, it is impor­
tant to discuss these risks with the patient beforehand.
As noted above, the donor defect resulting from harvest
of a wide flap (2.5–3.0 cm) will necessitate closure under
tension if closed primarily. This may result in restriction of
jaw opening, dysfunction of the buccinators, and possible
obstruction of the parotid duct flow. In these cases, the
application of a full-thickness skin graft or use of local
mucosal flaps to decrease tension on the donor site closure
may be required.
SUBMENTAL FLAP
INTRODUCTION
The submental artery flap is a thin and pliable flap that is
commonly used in reconstruction of defects of the head and
neck. First described by Martin et al. in 1992, multiple
studies have confirmed the versatility of the submental flap,
and its uses have expanded to include reconstruction of the
face, neck, and oropharynx.13 The submental flap is espe­
cially useful in reconstruction of the face as it has a good
color and texture match with surrounding skin and provides
retromolar region to treat certain palatal or floor of mouth
defects, allowing inset of the flap in one stage without the
need for secondary division. When routing posteriorly, the
mucosa posterior to the molars may be divided, excised, or
elevated and used for other purposes.
The FAMM flap can be used for reconstruction of the
nasal lining provided that the defect is at the level of the
middle nasal vault or posterior to this. Anteriorly placed
FAMM flaps in the nasal vestibule may produce excessive
mucus that can be an annoyance with constant nasal dis­
charge and crusting. If used for nasal lining, the FAMM flap
is superiorly based. Access to the nose is gained through a
gingivobuccal sulcus incision, and the flap is tunneled
through the piriform aperture into the nasal vault. When
closing this incision, the mucosa of the flap should be gently
separated from the buccinator muscle attachments during
its course from the intraoral to the intranasal space allowing
for direct mucosa to mucosa closure of both spaces, thus
circumventing the development of an oronasal fistula.
The FAMM flap has great applicability for lip and vermil­
lion reconstruction.12 Orientation of the facial artery pedicle
lends itself well to transposition of these flaps with primary
inset. So as to avoid donor site morbidity, the design and
elevation of long thin flaps is desirable. Compared with
tongue and cross-lip flaps that require secondary division
and inset, the FAMM flap carries a significant advantage in
being completed in one stage. Additional advantages of the
FAMM flap for lip and vermillion reconstruction include its
bulkiness and complementary color match.
FLAP DIMENSIONS
Width: 1–2 cm, maximum 3 cm
Length: 5 cm, maximum 7–8 cm
TECHNIQUE OF FLAP HARVEST (Case 31.2,
Fig. 31.4)
The patient is placed in the supine position with the neck
slightly extended and a shoulder roll used if necessary. A
Dingman mouth prop, bite block, or dental molt may be
placed in the mouth in order to facilitate exposure. Alter­
natively, retraction sutures may be used instead to facilitate
exposure and dissection. Next, the course of the facial artery
is determined by Doppler exam and is then marked on the
oral mucosa. The flap width is determined by the size of
the defect, and the flap is then designed to be centered on
the facial artery. An incision is then made across the distal
end of the flap (either superior or inferior depending on
the flap orientation), and dissection is carried through the
mucosa, submucosa, and buccinator muscle, until the facial
artery is identified and ligated. Incisions paralleling the
facial artery are then made on the anterior and posterior
sides of the flap, and dissection is again extended through
the buccinator muscle with direct identification of the facial
artery. The flap is then elevated from distal to proximal,
taking special care to include the facial artery within the
flap. Once the flap is elevated in its entirety, it is transposed
into the defect. It is important to preserve a cuff of soft
tissue/adventitia around the facial artery during flap eleva­
tion to avoid injury to the venous plexus and hence, venous
drainage from the flap.

376
PART 4 — CONVENTIONAL WORKHORSE FLAPS
itself. As it courses medially, the submental artery gives off
branches to the submandibular and sublingual glands, a
branch to the mylohyoid, a branch to the mandibular peri­
osteum, a digastric branch, and skin perforator branches.
There are typically 2–4 skin perforator branches that may
pass medial, lateral, or through the anterior belly of the
digastric muscle. Most commonly, there are two major per­
forators, one of which emerges lateral to the anterior belly
of the digastric and the other of which emerges just medial
to the anterior belly of the digastric. Minor perforators typi­
cally pass through the belly of the muscle itself. As the
submental artery ends, it may contribute to a rich subdermal
plexus or even anastomose to the contralateral submental
artery, both of which allow elevation of the entire submental
region.14
VENOUS DRAINAGE OF THE FLAP (See Figs 10.4
and 10.5)
Primary:  submental vein 2.2 mm (range 1–3 mm)
The submental vein is one of the tributaries of the facial
vein, and enters the facial vein approximately 2 cm (range
0.7–3 cm) from the facial vein origin. Typically, the submen­
tal vein accompanies the submental artery along its course.
The submental vein provides the venous drainage to the
flap and typically runs alongside the submental artery, deep
to the platysma and superficial to the mylohyoid before
joining with the common facial vein. The common facial
vein typically runs lateral to the facial artery and enters the
submental region deep to the platysma. The facial vein most
commonly empties into the internal jugular vein; however,
multiple variants in this drainage pattern have been
described. The facial vein may occasionally empty into the
external jugular vein, the subclavian vein, or empty into the
internal jugular vein with a separate connection to the exter­
nal jugular vein.
FLAP INNERVATION (Fig. 31.2 and See Fig. 10.11)
The platysma muscle is innervated by the cervical branch of
the facial nerve. Sensibility to the submental region is pro­
vided by the transverse cervical nerves (Fig. 31.2).
FLAP DESIGN
ANATOMIC LANDMARKS (Case 31.3, Fig. 31.5)
The course of the facial artery is first identified by Doppler
traversing across the inferior mandibular border near the
mandibular notch and is marked. The upper border of the
flap is marked along the inferior border of the mandible,
extending from the mandibular angle to a corresponding
point on the contralateral side depending on the desired
flap size and configuration. In order to minimize the risk of
damage to the marginal mandibular nerve, the upper
border of the flap should remain 1 cm below the inferior
border of the mandible, especially in the region of the flap
that is posterior to the facial vessels. To ensure optimal flap
perfusion the inferior border of the flap should not extend
below the level of the thyroid cartilage. The donor site can
be closed primarily if the neck skin between the superior
and inferior flap borders can be easily approximated as
determined by a simple pinch test using the thumb and
index finger. In some cases, and especially in younger
hair-bearing skin in males. The flap may be harvested as a
pedicled or free flap, and its low donor site morbidity and
consistent anatomy have made it a mainstay in head and
neck reconstruction.
FLAP ANATOMY (Fig. 31.2 and See Figs 10.4, 10.5)
The submental flap is harvested from the submental region,
extending from mandibular angle to mandibular angle, pos­
terior to the inferior border of the symphyseal region of the
mandible. In this area, skin, subcutaneous fat, and the pla­
tysma comprise the anterior compartment, which is bor­
dered on its deep surface by the mylohyoid muscle. The facial
artery and vein lie in this plane and give off the submental
vessels before passing over the mandibular border. The facial
vessels may be intimately attached to the submandibular
gland, which is commonly encountered in the lateral part of
the submental region, inferior and deep to the man­dibular
angle. The anterior bellies of the digastric muscles are located
in the subplatysmal plane as well and attach to the inferior
symphyseal border. Also residing in the subplatysmal plane
is the marginal mandibular nerve, which is located above the
mandibular border 80% of the time in the region posterior
to the facial vessels (see Fig. 10.11).
ARTERIAL AND VENOUS SUPPLY OF THE FLAP
ARTERIAL SUPPLY OF THE FLAP (See Figs 10.4 and 10.5)
The submental flap is supplied by the submental artery,
which is one of the terminal branches of the facial artery.
In most cases, the facial artery branches directly from the
external carotid (80–90%); however, it may share a common
trunk with the lingual artery (10–20%). At its origin the
diameter of the facial artery is approximately 3.3 mm
(range 2.7–3.9 mm) and typically is found 19.6 mm (range
10.9–28.3) from the carotid bifurcation. After branching
from the external carotid, the facial artery courses obliquely
toward the mandible, where it passes beneath the posterior
belly of the digastric muscle and the stylohyoid, as well as
the submandibular gland. Occasionally, the facial artery may
be intimately associated with the submandibular gland
before passing over the inferior border of the mandible
~25 mm from the mandibular angle. The facial artery gives
off several branches in the neck: the ascending palatine
branch (which may stem from the external carotid artery),
the tonsillar branch, multiple glandular branches to the
submandibular gland, and the submental branch.
Dominant:  submental artery
Length: 6 cm (range 3.5–10 cm)
Diameter: 1.7 mm (range 1–2 mm)
The submental artery is the largest of the terminal
branches of the facial artery, with a diameter of 1–2 mm at
its origin. The submental artery takes off from the facial
artery at a mean of 4.5 cm (range 1.9–5.7 cm) from the
origin of the facial artery at a point 7 mm below the inferior
border of the mandible. At its point of origin, the submental
artery is located deep and medial to the submandibular
gland although this position is variable and the artery may
be located superficial to the gland or even within the gland

CHAPTER 31 — LOCAL FLAPS IN THE HEAD AND NECK
377
Figure 31.5  (A,B) Preoperative views of the patient showing the reconstruction with a radial forearm flap. (C) A template of the area to
be reconstructed was made from X-ray film. (D) The template was positioned to optimize the orientation of the hair follicles in the sub­
mental region to approximate the beard growth pattern on the left upper lip and cheek. (E) In this case, the prior free flaps had been
based on the right facial vessels. Preliminary exploration revealed that the submental artery on this side had been divided. A pedicled
submental flap was therefore not possible and the flap had to be transferred as a microvascular free flap based upon the left submental-
facial system. The submental pedicle has been dissected to demonstrate the submental artery (SMA), the facial artery (FA), the facial vein
(FV), and the marginal mandibular branch of the facial nerve (MM Branch VII). (F) The flap is elevated on its vascular pedicle comprised
of the facial artery and facial vein. (G) The flap is shown following inset into the facial defect. Vascular repairs were made to the pedicle
of the previous radial forearm flap. (H) The submental defect is closed with a full-thickness supraclavicular skin graft. In most cases, the
submental defect can be closed primarily and especially in older patients or in cases employing smaller flaps. (I,J) The patient is shown
6 months following transfer. The flap exhibits luxuriant beard growth that camouflages the defect. Further debulking of the flap will be
performed to improve contour.
A
B
C
D
E
F
G
H
I
J
A 55-year-old man following two radial forearm flaps for recon-
struction of a composite cheek defect for dermatofibrosarcoma
protuberans. Restoration of the beard area of the right upper
lip and cheek was planned using a submental flap.
CASE 31.3  Right Cheek and Lip Defect Resurfaced with a Pedicled Submental Flap

378
PART 4 — CONVENTIONAL WORKHORSE FLAPS
the contralateral lower margin of the flap is incised sharply
and dissection is carried down through the platysma. Next,
the inferior margin of the flap is undermined and elevated
in the cephalad direction to the mylohyoid muscle. As the
dissection proceeds toward the midline, the contralateral
anterior belly of the digastric muscle is encountered and
dissection proceeds superficial to this muscle. Arterial and
venous branches that emanate from around and through
the anterior belly of the contralateral digastric muscle to the
overlying platysma are divided. Once the flap has been com­
pletely undermined to the mandibular border on its contra­
lateral side, the marginal mandibular nerve should be
identified and protected.15 Once it is ensured that the mar­
ginal mandibular nerve is not included within the flap, the
anterior border of the flap is incised through the platysma
and dissection proceeds toward the ipsilateral side in the
subplatysmal plane.
Dissecting along the ipsilateral inferior flap margin, the
tendon of the anterior belly of the digastric muscle is identi­
fied. The tendon is divided and the anterior muscle belly is
included with the flap. As the dissection proceeds cephalad,
the submental vascular pedicle will be identified lying in the
plane between the anterior belly of the digastric and the
mylohyoid muscle. Multiple vascular branches from the sub­
mental pedicle to the mylohyoid are carefully ligated with
fine sutures or micro hemoclips and divided. The submen­
tal vascular pedicle will now be clearly visualized and can be
dissected laterally behind the submandibular gland toward
the facial vessels. The motor nerve to the mylohyoid muscle
may be encountered laterally and can be divided if it inter­
feres with pedicle dissection or flap rotation. As the pedicle
passes under the submandibular gland, branches to the
gland are ligated and divided as necessary for flap transposi­
tion. If additional mobility of the flap is necessary, the facial
vessels may be dissected free from their surrounding attach­
ments and can be divided proximal or distal to the takeoff
of the submandibular vessels as necessary to increase the arc
of rotation.
If an extended pedicle length or a free flap based on the
facial artery/vein system is contemplated, resection of the
submandibular gland may be necessary for access. Multiple
vascular branches from the facial artery and vein supplying
the submandibular gland are divided and the gland is care­
fully dissected out of its fossa, with care taken to avoid injury
to the hypoglossal nerve lying in the depths of the subman­
dibular fossa.
The last step in flap dissection is division of the superior
border of the flap where the platysma joins the inferior
margin of the mandible. As noted above, care must be taken
to avoid injury to the marginal mandibular branch of the
facial nerve. The course of the marginal mandibular branch
of the facial nerve varies considerably, but in most cases it
lies 1–1.5 cm below the mandibular margin to the mid-point
of the mandibular ramus between the angle and the sym­
physis. Anterior to this mid-point, the marginal mandibular
branch of the facial nerve lies at or above the mandibular
margin. During flap dissection, it is helpful to visually iden­
tify the nerve from the undersurface of the platysma and
divide the platysma under direct visualization of the nerve.
By designing the flap 1 cm below the inferior mandibular
margin anterior to the ramus mid-point, additional safety
against injury to the nerve is provided.
patients, the donor site may require closure with a skin graft
to avoid tension and restriction of neck extension.
GENERAL THOUGHTS ABOUT FLAP DESIGN
Care should be taken when considering the use of this flap
in patients with prior neck dissections as the submental
artery may be a dominant source of blood supply to the
tongue if the lingual vessels have been sacrificed in a bilat­
eral neck dissection.
For pedicled flaps, a limiting factor in the arc of rotation
of the flap is typically the submental vein as the artery is
tortuous and allows for an extended arc of rotation. In
general, the facial vein is found lateral to the facial artery
and if it is limiting the arc of rotation, it can be divided and
re-anastomosed to the external jugular vein or a more proxi­
mally located venous conduit to increase effective pedicle
length.
The submental flap tends to be bulky and may require
additional thinning procedures. The overall bulk of the flap
may be decreased by elevating it in the supraplatysmal plane
as a fasciocutaneous flap based on perforators from the
submental artery. This dissection can be somewhat tedious
and is at risk for injuring the delicate perforating vessels
from the submental system.
When a larger skin paddle is required, the donor site can
be pre-expanded to allow for flap greater size. Alternatively,
a larger flap may be harvested primarily with skin graft
closure of the donor defect.
The platysma muscle can be functional if desired. In this
case, dissection should proceed laterally to identify the cer­
vical branch of the facial nerve and include it in the dissec­
tion (see also Ch. 15).
FLAP DESIGNS FOR PARTICULAR TYPES
OF RECONSTRUCTIONS
The submental flap is typically elevated as a myocutaneous
flap, in the subplatysmal plane. As noted above, the flap may
be raised in the supraplatysmal plane as a fasciocutaneous
flap based on perforators from the submental artery, but
this is rarely necessary. For skin defects or oropharyngeal
lining defects, the flap may be raised in the standard fashion
and can be tunneled into the defect. The flap may also be
elevated as an osteomyocutaneous flap, in which case a small
segment of mandible can be included based on submental
perforators to the mandibular periosteum. This configura­
tion has limited applicability in bony reconstructions of the
midface. Finally, the flap can be de-epithelialized and buried
in order to provide soft tissue bulk when indicated. When
used as a free flap, the submental flap has innumerable
applications.
FLAP DIMENSIONS
The skin paddle of the flap can be up to 7 × 18 cm and can
include skin, platysma, and bone if desired.
TECHNIQUE OF FLAP HARVEST (Case 31.3,
Fig. 31.5)
The patient is placed in the supine position with the neck
extended. After marking the flap as previously described,

CHAPTER 31 — LOCAL FLAPS IN THE HEAD AND NECK
379
donor site with a full-thickness skin graft and then later
perform serial excision of the graft as conditions allow.
Donor site scars resulting from harvest of the submental
flap are generally quite forgiving and are camouflaged by
their proximity to the inferior mandibular margin. Flap
color is nearly identical to that of the visible face. The hair-
bearing qualities of the submental flap are quite applicable
for reestablishing defects of the male beard. In designing
such flaps, it is important to coordinate the direction of the
beard hair growth in the flap with the recipient beard hair
growth.
NASOLABIAL FLAP
INTRODUCTION
The nasolabial flap was first described more than 2500 years
ago in the Sushruta Samhita.16 Since that time it has been
employed for local reconstruction of the nasal septum, ala,
and columella; the upper lip; and intraoral defects of the
floor, tongue, and gingival sulcus.16 The overlying skin pro­
vides an excellent color and texture match while the scar is
well hidden in a natural skin crease.17,18 These factors com­
bined with ease of harvest, reliability, and low donor site mor­
bidity make the nasolabial flap an excellent option for nasal
and upper lip reconstruction.
FLAP ANATOMY (Figs 31.2, 10.4 and 10.5)
The nasolabial flap is harvested from the medial cheek
region and extends from the level of the medial canthus to
the oral commissure, or slightly lower depending upon the
level of the defect, paralleling the nasolabial fold. Flaps can
be designed up to 3 cm in width depending on the laxity of
the cheek skin.16 The skin and subcutaneous fat comprise
the thickness of the flap, leaving the underlying nasalis,
levator labii superioris, and zygomaticus major muscles in
place.
The blood supply of the flap is a combination of perfora­
some and random pattern dermal/subdermal plexus vascu­
lar territories that overly the anatomic course of the facial
artery and its major tributaries. While the facial artery is not
harvested with the flap, it supplies a proximal perforasome
and its random dermal plexus extension through perforat­
ing branches to the overlying subcutaneous tissue and skin.
The facial artery lies just below the zygomaticus major, but
as it progresses superomedially it becomes more superficial
and can ultimately pass either over or under the levator labii
superioris as the angular artery. It is frequently embedded
within the muscle fibers, just below the dissection plane.
The facial vein typically takes a more direct course and
although it is consistently deep to the artery, is often some
distance away.
ARTERIAL AND VENOUS SUPPLY
(See Figs 10.4, 10.5)
It is worth noting that the nasolabial flap described here is
technically random, although work by Hynes and Boyd indi­
cates that is has an “axial nature” to its blood supply.16 There
With the submental island flap isolated to its pedicle, the
flap should be transposed to its target site to evaluate posi­
tioning. If additional length is needed, the vascular pedicle
can be further dissected as described above.
DONOR SITE CLOSURE AND MANAGEMENT
The donor site is typically closed primarily in layers. A drain
may be included if desired but is typically not necessary. The
sutured incisions are left exposed and dressed with topical
antibacterial ointment. Compressing bandages are not nec­
essary. If primary closure cannot be achieved after flap
harvest, a small full-thickness skin graft can be used for
closure.
FLAP USAGE
Indications: The submental flap is indicated for use in defects
of the head and neck, including skin defects, defects of the
oropharynx, soft tissue volumetric defects, and osteocutane­
ous defects. In certain situations, the submental flap can
have utility as a free flap for restoration of hair-bearing por­
tions of the face in males.
The arc of rotation of the flap allows it to reach the
entirety of the ipsilateral face, extending to the forehead.
This flap may reach deep posteriorly and can be used for
defects of the posterior pharynx and retropharyngeal space.
When using the flap as a pedicled flap, if more length is
required, the pedicle can be dissected back to the facial
vessels, which may add up to 3 cm of reach. If additional
length is required in the cephalad direction, the facial
vessels may be divided just proximal to the origin of the
submental vessels, and the flap will survive on retrograde
flow. Care must be taken to avoid injury to the marginal
mandibular nerve in this instance.
When elevating the flap as an osteocutaneous flap, the
inferior border of the mandible is typically used as the
source of bone. The bone can be harvested full thickness or
with just the lingual cortex. Care must be taken to avoid
damage to the tooth roots or inferior alveolar nerve when
bone is harvested.
POSTOPERATIVE CARE AND
EXPECTED OUTCOMES
In general, submental flaps do not require specialized
postoperative care and are well tolerated by patients. The
most common complications reported in the use of this
flap are the occasional marginal mandibular nerve palsy
and venous congestion. In order to minimize the risk of
marginal mandibular nerve injury, the nerve should iden­
tified and protected prior to incising the superior edge of
the flap. Additionally, including the anterior belly of the
digastric muscle in the flap can reduce the incidence of
venous congestion as this preserves additional vasculature
to the skin paddle. If venous congestion exists, the contra­
lateral submental vein can be anastomosed to a recipient
vein after inset of the flap to provide additional venous
outflow.
Larger flaps impose greater challenges for management
of the submental donor site. Large defects closed primarily
can impair neck extension and be quite uncomfortable for
the patient. In these situations it is prudent to close the

380
PART 4 — CONVENTIONAL WORKHORSE FLAPS
the facial vein is typically cited as the ultimate recipient of
venous outflow.
FLAP INNERVATION (Figs 31.2 and 10.10)
Flap sensation comes from cutaneous branches of the V2
(maxillary) division of the trigeminal nerve (cranial nerve
V). There is no motor innervation to the subcutaneous
nasolabial flap.
FLAP DESIGN
ANATOMIC LANDMARKS (Case 31.4, Fig. 31.6)
The course of the facial artery in the cheek is identified by
Doppler. The axis of the flap is marked along this line,
which is just lateral to the nasolabial crease overlying the
nasolabial fold. The base of the flap can be located any­
where along this line from just below the medial canthus of
the eye to the mid-jowl region. Owing to the perforasome
nature of its blood supply, the flap can be based proximally
or distally, and this will be determined by the particular
geometry of the defect being treated and the ease at which
the flap can be delivered to the defect without tension or
kinking. A suitable length is selected and the distal tip of
the flap is drawn to match the defect. The medial edge of
the flap should lie on or parallel to the nasolabial fold as
much as possible.18 A pinch test should be used to confirm
that the donor site will close primarily.
GENERAL THOUGHTS ABOUT FLAP DESIGN
If based upon a given perforator system, the flap can techni­
cally be raised as an island flap and transposed into the
defect. This requires precise identification of the perforator,
which can be technically difficult and risks inadvertent injury
to the perforator by the dissection required to identify
it. Because the facial artery perforators cannot be identified
by Doppler beforehand, most flap designs utilize a dermal
cutaneous pedicle design to optimize venous outflow. Given
the general location of the facial artery perforators, flap
design can be oriented to take advantage of these perforat­
ing systems without specific knowledge of their precise
location as long as the flap is oriented over the identified
course of the facial artery. Because of the facial artery’s
capability of both antegrade and retrograde flow, the flap
can be successfully raised even when the ipsilateral facial
artery or angular artery has been ligated. In these situations,
it is important to identify Doppler flow in the facial artery
beforehand and orient the flaps base toward the point of
inflow.
The distal end of the flap should be tailored to fit the
defect comfortably so as to avoid undue tension on the flap
at inset.18 It is often helpful to design the flap inset portion
slightly (1–2 mm) larger than the defect to avoid tension.
Defects lying beyond immediate proximity to the nasolabial
crease are closed by “jumping” the flap over intact skin
and insetting only the distal portion into the defect. Later,
flap division and inset will be required to complete the
reconstruction. Tunneling the flap beneath a skin bridge
to reach its target defect carries risk for compromising
the dermal circulation and should be avoided in most
situations.
is a rich dermal-subdermal plexus oriented along the naso­
labial fold that supplies the most distal edges of the flap.
The dominant arterial supply to this region is the angular
branch of the facial artery or, alternatively, the alar branch
of the superior labial artery (itself a terminal branch of the
facial artery). Contributions from the transverse facial artery
and even from contralateral labial vessels are suggested by
the successful use of this flap even when the ipsilateral facial
artery has been ligated.16
As previously mentioned, the subcutaneous nasolabial
flap has a random blood supply bolstered by a robust
dermal-subdermal plexus, the flow of which is oriented par­
allel or “axial” to the nasolabial plane. This dermal capillary
network is supplied by the facial artery through communi­
cating “perforator” branches that emanate from the main
trunk of the facial artery or one of its branches.19 There are
on average five main perforators of the facial artery in the
cheek, with each providing perfusion to the overlying
dermal-subdermal plexus and skin. Each of the perforators
supplies a unique vascular territory or “perforasome.”19 The
territorial extent of each of the perforasomes is not known
but likely varies from individual to individual. Facial artery
perforators seem to be mainly located 1.5 cm lateral to the
level of the oral commissure along the axis of the nasolabial
fold. It appears that each perforator from the facial artery
supplies a “patch” of overlying skin. One might then extrap­
olate that the “axial” nasolabial flap is simply an axial pattern
flap design that incorporates a perforasome territory at its
base, which, in turn, randomly connects to a secondary
perforasome comprising the distal extension of the flap.
This concept allows for a wide variety of flap designs based
proximally or distally along the nasolabial fold.19,20
As with the arterial supply, the venous drainage of the
subcutaneous nasolabial flap is technically random, but ulti­
mately empties into the facial vein tributaries via connec­
tions through the cutaneous perforators.19–21
Dominant:  facial artery (random); facial vein (random)
Cadaveric studies have demonstrated five main branch
patterns of the facial artery with either an angular artery
(classic pattern) or a lateral nasal artery (nasal pattern)
being the most and second most common patterns depend­
ing upon the author.22 Classically, the facial artery enters the
face by crossing the inferior border of the mandible near
the sigmoid notch. From there it takes a tortuous superior
and medial course. It gives off an inferior labial branch at
the angle of the mouth followed almost immediately by a
superior labial branch. The nasal artery arises at the alar
base and follows its curve to supply the nasal dorsum while
the facial artery terminates as the angular artery.22 Collateral
supply to this region includes contralateral anastomoses
between the inferior labial, superior labial, and nasal arter­
ies as well as the ipsilateral ophthalmic, infraorbital, and
transverse facial arteries.17,19,22
The facial vein originates near the medial canthus as the
angular vein. It follows a less tortuous course than the facial
artery and receives tributaries equivalent to its arterial coun­
terpart: nasal, superior labial, and inferior labial. The facial
vein ultimately exits the face by crossing the mandibular
border posterior to the facial artery and emptying into the
internal jugular vein. For most of its course, the facial vein
its deep and posterior to the facial artery.19 As with the arte­
rial supply, the venous drainage of this flap is random, but

CHAPTER 31 — LOCAL FLAPS IN THE HEAD AND NECK
381
FLAP DIMENSIONS
Flaps as large as 7 cm in length with a 3 cm base have been
reported and can include skin and subcutaneous tissue.16,18,19
Some authors have suggested improving the viability and
territory of the flap by raising the facial/angular artery and
hence the overlying adjacent facial mimetic muscles with
the flap, but the facial muscle weakness resulting from such
a maneuver would substantially increase the morbidity of
this flap.16
TECHNIQUE OF FLAP HARVEST (Case 31.4,
Fig. 31.6)
A foil template 1–2 mm larger than the original defect (or
a reversed template from the intact contralateral subunit),
FLAP DESIGNS FOR PARTICULAR RECONSTRUCTIONS
Superiorly based nasolabial flaps are particularly useful for
closing defects of the nasal dorsum, side wall, ala, and alar
rim. Concomitant cartilaginous defects can be recon­
structed simultaneously or as a second stage. As with any
other nasal reconstruction, if more than 50% of the subunit
is missing, the remaining skin should be discarded and the
subunit reconstructed in its entirety.4 The flap should be
tailored to comfortably fit the defect encountered and due
to its rich dermal-subdermal plexus, it can be thinned of
a major component of its subcutaneous layer to facilitate
its inset.
Inferiorly based nasolabial flaps are constructed on
similar principles and can be used for defects of the upper
lip and columella. These flaps, however, are prone to edema
and can significantly distort the oral commissure.18
The patient is a 54-year-old woman with basal cell carcinoma
of the right nasal ala. Wide local excision was performed
followed by reconstruction with a nasolabial flap. The patient
healed well.
CASE 31.4  Right Nasal Defect Reconstructed with a Pedicled Superiorly Based
Nasolabial Flap
Figure 31.6  (A) Wide excision is planned. A nasolabial island flap is designed over the nasolabial fold allowing for the donor closure to
lie in the nasolabial crease. (B) The surgical defect. (C) The flap is elevated to include a perforating branch of the angular artery. The rich
axial network of the subdermal/subcutaneous plexus allows conversion of the peninsular flap to an island configuration to facilitate inset
and closure. (D) The flap is transferred into the defect and inset. Primary closure of the donor defect required undermining of the adjacent
cheek skin to accommodate the subcutaneous pedicle. (E) The healed wound is shown at 9 months postoperatively. Further debulking
of the flap was required to correct the “biscuit” deformity. Biscuiting of the flap can often be circumvented by avoidance of round or oval
wound defects. In this case creation of a more geometric configuration of the defect and flap may have stifled the centric contraction that
resulted in this biscuit deformity.
A
B
C
D
E
C

382
PART 4 — CONVENTIONAL WORKHORSE FLAPS
is created. This serves to define the outline of the distal flap
and to ensure precise coverage of the defect. The length of
the flap pedicle is then calculated to ensure easy transposi­
tion and reach to the defect site. The flap is then drawn
along the course of the nasolabial crease with its base situ­
ated at the optimal pivot point of the transposition. As noted
above, location of the flap base is calculated to lie in line
with the anticipated site of the perforating branch(es) of
the facial/angular artery system to optimize the blood
supply of the flap. If elected, the precise location of the
perforator can be determined by a preliminary incision
along the medial limb of the pedicle and loupe dissection
along the superficial plane of the facial muscles directly
overlying the Dopplered course of the facial artery.20 If car­
tilage grafts are being placed in a single stage reconstruc­
tion, this should be taken into account when the template
is created. The distal flap skin is then elevated with a few
millimeters of subcutaneous tissue. As the dissection pro­
ceeds toward the flap base, the dissection becomes deeper
5–10 mm from the flap base to optimize inclusion of the
proximal facial/angular artery perforators. The rich dermal
blood supply of the nasolabial skin allows for significant
thinning of the distal flap.18
Flap elevation is complete when the flap can be mechani­
cally transposed to the defect site without tension. The flap
is then transposed into position and inset. During inset, the
flap can be thinned to a level that is just deep to its sub-
dermis, leaving a thin layer of fat to protect the random
dermal capillary network.18 Proximal thinning of the flap
base should be reserved for secondary revision to avoid
inadvertent injury to the perforating vessels.
Finally, the reconstruction should be assessed to ensure
that the curvature of the cheek has been reestablished, that
the contour of the nasal reconstruction is symmetric, and
that no iatrogenic ectropion has been created.18 The flap
should rest in the defect without tension or elevation.
DONOR SITE CLOSURE AND MANAGEMENT
The donor site is closed directly; some undermining may be
necessary based on the laxity of the local cheek skin. Skin
grafting is only occasionally required, and this should be
considered before raising the flap given its cosmetically sen­
sitive location. Drains are not typically required. Dressings
are kept to a minimum so as to observe flap perfusion. Typi­
cally a light dressing of antibiotic ointment along the suture
lines is all that is required. Pedicled flaps are dressed with
petrolatum-impregnated gauze covering the exposed, sub­
cutaneous surface of the flap pedicle.
FLAP USAGE
Indications: Superiorly based flaps are indicated for recon­
struction of the nasal sidewall, dorsum, and alar rim.
Inferiorly based flaps can be used for reconstruction of the
upper lip and columella. Some surgeons have used this flap
to reconstruct nasal lining and to fill intraoral defects
including the floor of the mouth, tongue, and gingival
sulcus, although these techniques are not described here.16
In each case, the flap includes skin and subcutaneous tissue
with de-epithelization of its trans-cheek course as necessary.
Sacrificing facial mimetic muscles to include the facial
artery with the flap may improve its vascularity, but as
noted above, carries considerable morbidity in loss of lip
animation.
The arc of rotation allows the flap to reach the entire
ipsilateral nose (including tip) and upper lip as well as some
intraoral structures including the gingival sulcus, tongue,
and oral floor.
POSTOPERATIVE CARE AND EXPECTED OUTCOMES
No special postoperative care is required, and the nasolabial
flap is well tolerated by most patients. Postoperative edema
is common and may take several weeks to resolve. For both
superiorly and inferiorly based flaps, secondary debulking
of the flap may be required to reestablish aesthetic facial
contours. For pedicled flaps, division of the pedicle and
inset is required 3–6 weeks later.
CERVICOFACIAL FLAP
INTRODUCTION
The cervicofacial flap is a workhorse flap for moderate and
large sized defects of the cheek.23,24 It allows for coverage of
large defects by mobilizing the substantial and lax skin of
the lateral face and neck while providing an acceptable
cosmetic outcome by placing incisions at the junctions of
the aesthetic facial subunits.23–25 It provides excellent color
match and, depending upon the surgeon’s chosen tech­
nique, the flap can be raised as a thin subcutaneous flap or
as a composite flap when more bulk is needed.
FLAP ANATOMY (Fig. 31.2 and See Figs 10.4,
10.5, 10.10, 10.11)
The cervicofacial flap is used primarily for reconstruction
of moderate and large sized defects of the anterior or pos­
terior cheek and as such relies on the surgeon’s knowledge
of facial aesthetic subunits. Incisions for the flap generally
follow the borders between the cheek and nasal aesthetic
units and the cheek and lower eyelid units. As well, the
posterior incision follows the anterior and posterior periau­
ricular lines and then extends along the occipital hairline
to the supraclavicular region.
In elevating the flap, the surgeon must be aware of the
location of the various facial nerve branches to avoid nerve
injury and facial motor paralysis (see Fig. 10.10). The zygo­
matic branch of the facial nerve is encountered in the gap
between the zygomaticus and levator labii muscles; main­
taining the dissection plane superficial to the superficial
musculoaponeurotic system (SMAS) avoids these branches.25
Buccal branches of the facial nerve are relatively large and
are encountered traversing the buccal fat pad; maintaining
the dissection plane superficial to the SMAS and platysma
avoids these branches.24
Two major arterial systems supply perfusion to the cervi­
cofacial flap: the transverse facial artery and the facial
artery proper.24 The transverse facial artery or (zygomatico-
orbital artery) is encountered as a branch of the superficial
temporal artery just inferior to the zygomatic arch. The
facial artery, a branch of the external carotid, enters the
cheek from the neck, crossing around the lower border of

CHAPTER 31 — LOCAL FLAPS IN THE HEAD AND NECK
383
the mandible, at the mid ramus, and coursing in an oblique
direction toward the nasal ala. The facial and transverse
facial arteries provide perforating branches to the overly­
ing subcutaneous tissues and skin. Each of these per­
forating branches supplies a dermal perfusion zone, or
“perforasome,” that in turn communicates with adjacent
perforasomes via the dermal and subdermal plexus of the
facial skin. The anterior facial vein generally parallels the
course of the facial artery lying slightly posterior to it. Simi­
larly, the transverse facial vein parallels the course of the
transverse facial artery emptying into the superficial tempo­
ral vein and thence to the retromandibular and internal
jugular veins.
ARTERIAL AND VENOUS SUPPLY (See Figs 10.4,
10.5)
The external carotid and internal jugular systems provide
the primary arterial and venous supply to the cervicofacial
flap. Although the branch pattern of the external carotid
artery is quite predictable, there is substantial variation in
the course and branch pattern of the facial artery.26 In
general, for an inferior and posteriorly based cervicofacial
flap, the transverse facial artery provides the major source
of inflow to the flap, while an anterior and inferiorly based
flap is primarily supplied by the facial artery proper.24 An
anteriorly and inferiorly based flap may require sacrificing
the transverse facial artery system to gain sufficient mobility.
Venous drainage of the cervicofacial flap is primarily
through the internal jugular system via the transverse facial-
retromandibular system and the facial-internal jugular
system.27,28 Secondary venous drainage of the flap occurs
through the cavernous sinus via ophthalmic, infraorbital,
and deep facial veins.
Dominant:  facial artery and transverse facial artery (see
Figs 10.4A, 10.5)
FACIAL ARTERY
The facial artery originates from the external carotid in the
vast majority of cases, entering the face by crossing the infe­
rior border of the mandible in the vicinity of the sigmoid
notch or mid-ramus. It follows an oblique course anteriorly
and superiorly toward the angle of the mouth. From there,
it passes toward the alar base and along the lateral edge of
the nose, terminating at the medial canthus as the angular
artery. Its course lies superficial to the buccinators and
levator anguli oris but deep to the levator labii superioris,
risorius, and zygomaticus muscles.26
The facial artery has four major branches on the face;
from proximal to terminal they are inferior labial, superior
labial, lateral nasal, and angular arteries. The inferior labial
artery arises near the angle of the mouth, penetrating the
orbicularis oris and running along the edge of the lower lip.
The superior labial artery is somewhat larger and originates
just distal to the inferior labial, following the upper lip and
giving off 2–3 ascending branches toward the nose. The
lateral nasal artery arises at the alar base, following the ala
to supply it and the dorsum. The facial artery terminates as
the angular artery, running within the quadratus labii supe­
rioris toward the medial canthus. The first three vessels
anastomose with their contralateral counterpart.22 Along
the course of the facial-angular system and the transverse
facial system and their branches are numerous perforating
branches to the overlying subcutaneous fat and skin.22 These
constitute the main source of vascular inflow to the cervico­
facial flap. Collateral supply is also contributed by anasto­
moses to the ophthalmic, infraorbital, and transverse facial
arteries.
The transverse facial artery arises from the superficial
temporal artery about 3 cm below the zygomatic arch and
courses for 1–11 mm within the parotid gland. It divides
into two trunks of which the superior is the larger. The
superior trunk runs transversely between the superior edge
of the parotid gland and inferior border of the zygomatic
arch accompanied by the zygomatic branch of the facial
nerve. Many small branches supply the gland, the masseter,
and the overlying skin. Anastomoses occur between these
unnamed branches and the proper facial artery system.
There are typically 1–4 skin perforators (mean 2), most of
which arise from the superior trunk. The position of the
main perforator is consistently within 1.1 cm of the point
3.1 cm lateral to and 3.7 cm inferior to the lateral canthus.27,28
The facial vein is found posterior and deep to the facial
artery and follows a less tortuous course than its arterial
counterpart. It originates as the angular vein at the medial
canthus and travels obliquely posterior and inferior, leaving
the face by crossing the body of the mandible posterior to
the facial artery, eventually joining the internal jugular vein.
It receives tributaries along its course from the venous equiv­
alents of the facial artery branches: nasal, superior labial,
and inferior labial branches. As noted above, the transverse
facial vein parallels the course of the transverse facial artery,
emptying into the superficial temporal vein and thus the
retromandibular and internal jugular veins.
FLAP INNERVATION (Fig. 31.2 and See
Fig. 10.10)
Sensibility to the cervicofacial flap is provided by the second
(via infraorbital nerve) and third (via mental and auriculo­
temporal nerves) divisions of the trigeminal nerve. The
infraorbital nerve exits the infraorbital foramen located on
the maxilla 6–10 mm below the infraorbital rim and divides
into myriad branches supplying the skin from the palpebral
fissure to the mouth. The mental nerve exits the mental
foramen located on the mandible in line with the second
premolar tooth to provide sensibility to the lower lip, mouth,
and chin; the auriculotemporal nerve crosses the root of the
temporal zygomatic process and supplies the temporal skin,
external auditory meatus, and auricle.
The extent to which the cervicofacial flap retains sensibil­
ity will relate to the extent of dissection required to position
the flap at the target defect. Invariably, small sensory
branches supplying the skin of the flap will be divided
during flap elevation, and this is a necessary consequence
of flap execution. Flap insensibility is quite common, espe­
cially in larger flaps. In most cases, sensibility will return to
the flap over time but may never achieve preoperative levels
of discrimination.
Motor innervation to the region is supplied by the facial
nerve and relates to the facial musculature. During flap
elevation, care is exercised to avoid injury to the facial
nerves especially when dissecting in the danger areas as

384
PART 4 — CONVENTIONAL WORKHORSE FLAPS
FLAP DESIGN
ANATOMIC LANDMARKS (Case 31.5, Fig. 31.7)
Depending upon the location of the defect, the flap may
include transverse, cervical, and anterior incisions. The
transverse incision runs between the lower eyelid and cheek
aesthetic units toward the lateral canthus, then passes ante­
rior to the tragus and earlobe around to the occipital/cervi­
cal region. The length of the cervical incision depends upon
noted. Within the parotid gland, the facial nerve divides
into temporal, zygomatic, buccal, mandibular, and cervical
branches. In general, the nerve is most at risk at the anterior
border of the parotid gland. The zygomatic branches are
encountered in the gap between the zygomaticus and
levator labii superioris muscles, while the buccal branches
are found on the buccal fat pad, and the marginal mandibu­
lar branch courses in the vicinity of the inferior border of
the mandible.
Figure 31.7  (A) Preoperative image showing a pigmented lesion in the lower eyelid upper cheek region. The patient underwent a resec­
tion of the lesion with a 5 mm margin resulting in a defect measuring 4.5 cm in diameter. (B,C) Superimposed markings showing the
markings of the defect, the cervicofacial flap design, and the direction of rotation of the flap. (D–F) The patient is seen 3 months post-
resection and reconstruction with a cervicofacial flap. The flap was anchored to the periosteum of the orbital rim to prevent lower eyelid
retraction. (Courtesy of Samir Mardini, MD.)
A
B
C
D
E
F
The patient presented with a pigmented lesion in the right lower
eyelid and underwent a Mohs resection with a resultant defect
measuring 4.5 cm in diameter. Pathology showed a lentigo
maligna melanoma. The defect was reconstructed with a cervi-
cofacial flap. The patient healed without any complication and
without lower eyelid retraction.
CASE 31.5  Right Lower Eyelid and Upper Cheek Defect Reconstructed with a Pedicled
Cervicofacial Rotation Flap

CHAPTER 31 — LOCAL FLAPS IN THE HEAD AND NECK
385
the size of the defect and skin laxity. From the end of the
transverse incision, it follows the occipital hairline and con­
tinues down a line 2 cm posterior to the anterior border of
the trapezius.27 Care should be taken to avoid incorporating
the male sideburn area, which results in anterior displace­
ment of the hair-bearing skin. Anteriorly placed incisions,
when needed, parallel the border between the nasal and
cheek aesthetic units.23,24
The transverse facial artery perforator is typically found
within 1.1 cm of the point 3.1 cm lateral and 3.7 cm inferior
to the lateral canthus. Flaps based on the transverse
facial system should preserve this region to optimize flap
perfusion.
GENERAL THOUGHTS ABOUT FLAP DESIGN
Traditional cervicofacial flaps are at risk for distal ischemia
and necrosis, resulting in unsightly scars. This is particularly
problematic in smokers. A reversed cervicofacial flap may
be considered in this situation.
For optimal aesthetics, it is best to avoid advancing cheek
skin onto the lower eyelid if at all possible; this area is better
reconstructed by skin grafting. Additionally, ectropion can
result from a poorly designed cervicofacial flap that pulls
the eyelid skin downward in its transposed/advanced posi­
tion. Avoidance of lower eyelid extropion can be achieved
by designing the flap 1.5–2 cm higher than the level of the
lateral canthus and by anchoring the superior margin flap
to periosteum or bone along the lateral orbital rim above
the lateral canthus following its transposition.23,25 Overcor­
rection in the vertical plane is preferable to undercorrec­
tion as a small amount of excess tissue can be left in the
lower eyelid to allow for settling over time; this will result in
an initially full eyelid that will correct to approximate
normal contour within several months.24
FLAP DESIGNS FOR PARTICULAR RECONSTRUCTIONS
The cervicofacial flap is versatile in that it can cover both
large and small defects of the anterior or posterior cheek.
The flap is typically raised superficial to the SMAS plane,
although sub-SMAS techniques have been described that
incorporate the platysma, to improve vascularity, as a com­
posite musculocutaneous flap.25 At its most extreme, the
cervicofacial flap becomes a cervicothoracic flap.23
For defects at the extreme medial edge of the traditional
flap (nasal sidewall, medial periorbital, and anterior cheek),
a reversed cervicofacial flap may be a reasonable alterna­
tive. The incision is placed along the border of the nasal
sidewall and dorsum subunits and then follows the nasola­
bial crease.24 Limiting dissection to the level of the oral
commissure generally suffices for smaller defects. For larger
defects the incision is carried around the modiolus, inferior
to the oral commissure paralleling the border between the
lip and chin units. Finally, it curves around the chin aes­
thetic unit to the submental region, where it turns posterior
and lateral toward the ipsilateral cheek to recruit the sub­
mental skin.24
If a subciliary incision is needed rather than an incision
along the juncture of the lower eyelid and cheek, the supe­
rior edge of the flap should be aggressively thinned to
approximate native eyelid thickness. Anchoring the flap
along the zygomatic or inferior orbital periosteum and
maintaining an acute angle in the superomedial tip of the
flap may serve to reduce tension and the risk of lower lid
ectropion.23
FLAP DIMENSIONS
The dimensions of the cervicofacial flap vary widely depend­
ing on the size and location of the defect to be closed.
Although often discussed separately, the cervicothoracic
flap is simply an extreme inferior extension of the cervico­
facial flap.23 Depending upon the harvest technique (supra-
or sub-SMAS), it may include only skin and subcutaneous
tissue or include the SMAS and platysma as a composite
musculocutaneous flap.25,27 Various authors have reported
closing large defects (up to ≥10 cm) with the composite
cervicofacial flap.27
TECHNIQUE OF FLAP HARVEST (See Case 31.5
and Fig. 31.7)
The patient is placed in the supine position with the neck
extended. After marking as previously described, the trans­
verse and initial cervical incisions are made. Undermining
is performed superficial to the SMAS plane with attention
given to preserve the main perforating branches of the
transverse facial and the facial artery systems depending on
flap design, defect size, and the requisites for tissue move­
ment. Over the parotid, the dissection plane is kept super­
ficial to the parotid masseteric fascia so as to avoid injury to
the branches of the facial nerve.23 Special consideration
should be given to the anterior border of the parotid gland,
where branches of the facial nerve emerge. Judicious use of
bipolar electrocautery in this area will reduce postoperative
zygomatic and levator labii weakness.25
The cervical incision is continually reassessed and length­
ened as needed to allow the appropriate amount of rotation-
transposition for tension-free closure of the defect. Elevation
of the cervical portion proceeds in the subplatysmal plane
to provide for optimal perfusion of a larger flap. Staying
just below the platysma and dissecting under direct visualiza­
tion using loupe magnification will minimize risk to the
marginal mandibular nerve. Also, when dissecting either
the subcutaneous or composite cervicofacial flap, preserva­
tion of as many perforating branches as possible will opti­
mize flap perfusion. Having this goal in mind, dissection/
elevation can be in mind can best be accomplished by use
of operative loupe magnification.
If flap suspension is required, we prefer nonabsorbable
sutures placed in the periosteum. Commercially available
bone anchors may also be placed in the substance, the zygo­
matic arch, the inferior orbital rim, or the nasal facial
groove. The flap should be trimmed to allow a precise but
tension-free fit at the borders of the nasal, cheek, and eye
aesthetic units. After closure there should be no tension
whatsoever on the nasal ala, upper lip, or lower eyelid.23
The remaining incisions are closed in layers according to
the surgeon’s preference.
DONOR SITE CLOSURE AND MANAGEMENT
The donor site can typically be closed primarily, although
posterior undermining is usually required. In certain situa­
tions, a skin graft closure of the remaining gap resulting

386
PART 4 — CONVENTIONAL WORKHORSE FLAPS
from flap transfer may be required to minimize tension and
optimize flap perfusion. This can be excised secondarily by
serial excision as a minor procedure. Dressings are based
on the surgeon’s preference. For extensive dissections
involving considerable undermining, placement of a drain
may be indicated to minimize accumulations of blood and
serum beneath the flap.23
FLAP USAGE
The cervicofacial flap is indicated for closure of moderate
and large sized cheek, periorbital, periauricular, and cervi­
cal region defects. Anteriorly based cervicofacial flaps are
most useful for more posteriorly located defects, although
they can be used for larger anterior defects as well.23 Poste­
riorly and inferiorly based (reversed) cervicofacial flaps are
indicated for small and moderate sized defects of the ante­
rior cheek up to and including the nasal sidewall.24
The arc of rotation of the traditional cervicofacial flap
allows it to reach the ipsilateral cheek up to the medial
canthus and nasal-cheek aesthetic unit border. It may
include the lower eyelid when the defect extends into that
aesthetic unit. Posterior coverage reaches as far as the peri­
auricular region. Reversed cervicofacial flaps extend even
further medial to include defects of the ipsilateral nasal
sidewall and allow for recruitment of submental skin for
inferomedial, anterior cheek defects.
POSTOPERATIVE CARE AND
EXPECTED OUTCOMES
No specialized postoperative care is required for cervicofa­
cial flaps. Distal edge necrosis, when it occurs, is typically
allowed to heal by secondary intention.23 Lower eyelid ectro­
pion should be anticipated and avoided by anchoring as
described and lower lid tightening at the time of the initial
operation if needed or by leaving a small amount of excess
tissue to account for settling with time.23,24
When a sub-SMAS dissection plane is used, the branches
of the facial nerve are most at risk on the anterior border
of the parotid gland and between the zygomaticus and
levator labii muscles. Some weakness of these muscles is
expected in the immediate postoperative period, but failure
to improve should raise suspicion for nerve injury. The
marginal mandibular nerve is at risk during platysmal eleva­
tion in the cervical portion of the flap at the lower border
of the mandible. Care should also be taken to preserve as
many facial artery and transverse facial artery perforators as
possible during flap dissection and elevation to optimize
flap perfusion and reduce the risk of distal edge necrosis.
REFERENCES
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2004;113(6):110e–111e.
2. Kazanjian VH. The repair of nasal defects with median forehead
flap; primary closure of forehead wound. Plast Reconstr Surg
1947;2(2):184.
3. Millard DR Jr. Hemirhinoplasty. Plast Reconstr Surg 1967;40:440.
4. Burget GC, Menick FJ. Nasal reconstruction: seeking a fourth
dimension. Plast Reconstr Surg 1986;78(2):145–57.
5. McCarthy JG, Lorenc ZP, Cutting C, et al. The median forehead
flap: the blood supply. Plast Reconstr Surg 1985;76:866.
6. Reece EM, Schaverien M, Rohrich RJ. The paramedian forehead
flap: a dynamic anatomical vascular study verifying safety and clini­
cal implications. Plast Reconstr Surg 2008;121:1956–63.
7. Menick FJ. 10-Year experience in nasal reconstruction with the
three-stage forehead flap. Plast Reconstr Surg 2002;109(6):
1839–55.
8. Walton RL, Cohn AB, Beahm EK. Epidermal overgrafting improves
coloration in flaps and grafts applied to the face in reconstruction.
Plast Reconstr Surg 2008;121(5):1606–13.
9. Pribaz J, Stephens W, Crespo L, et al. A new intraoral flap:
facial artery musculomucosal (FAMM) flap. Plast Reconstr Surg
1992;90(3):421–9.
10. Pinar Y, Bilge O, Govsa F. Anatomic study of the blood supply of
the perioral region. Clin Anat 2005;18(5):330–9.
11. Hatoko M, Kuwahara M, Tanaka A, et al. Use of the facial artery
musculomucosal flap for closure of soft tissue defects of the
mandibular vestibule. Int J Oral Maxillofac Surg 2002;31(2):
210–11.
12. Pribaz JJ, Meara JG, Wright S, et al. Lip and vermillion reconstruc­
tion with the facial artery musculomucosal flap. Plast Reconstr Surg
2000;105(3):864–72.
13. Martin D, Pascal J, Baudet J. The submental island flap: a new
donor site. Anatomy and clinical applications as a free or pedicled
flap. Plast Reconstr Surg 1993;92(5):867–73.
14. Magden O, Edizer M, Tayfur V, et al. Anatomic study of the vascu­
lature of the submental artery flap. Plast Reconstr Surg 2004;114(7):
1719–23.
15. Moubayed S, Rahal A, Ayad T. The submental island flap for soft-
tissue head and neck reconstruction. A step-by-step video descrip­
tion and long term results. Plast Reconstr Surg 2014;133(3):
684–6.
16. Hynes B, Boyd JB. The nasolabial flap. Axial or random? Arch
Otolaryngol Head Neck Surg 1988;114:1389–91.
17. Hagerty RF, Smith W. The nasolabial cheek flap. Am Surg
1958;24:506–10.
18. Field LM. The nasolabial flap – a defensive reappraisal. J Dermatol
Surg Oncol 1990;16:429–36.
19. Qassemyar Q, Havet E, Sinna R. Vascular basis of the facial artery
perforator flap: analysis of 101 perforator territories. Plast Reconstr
Surg 2012;129(2):421–9.
20. Hofer SO, Posch NA, Smit X. The facial artery perforator flap for
reconstruction of perioral defects. Plast Reconstr Surg 2005;115:
996–1003.
21. Herbert DC, Harrison RG. Nasolabial subcutaneous pedicle flaps.
Br J Plast Surg 1975;28:85–9.
22. Niranjan NS. An anatomical study of the facial artery. Ann Plast
Surg 1988;21:14–22.
23. Chu EA, Byrne PJ. Local flaps I: bilobed, rhombic, and cervicofa­
cial. Facial Plast Surg Clin North Am 2009;17:349–60.
24. Al-Shunnar B, Manson PN. Cheek reconstruction with laterally
based flaps. Clin Plast Surg 2001;28:283–96.
25. Delay E, Lucas R, Jorquera F, et al. Composite cervicofacial flap for
reconstruction of complex cheek defects. Ann Plast Surg 1999;43:
347–53.
26. Niranjan NS. An anatomical study of the facial artery. Ann Plast
Surg 1988;21:14–22.
27. Helman JI. The cervicofacial flap in facial reconstruction. Oral
Maxillofac Surg Clin North Am. 2003;15:551–7.
28. Whetzel TP, Mathes SJ. The arterial supply of the face lift flap. Plast
Reconstr Surg 1997;100:480–8.

e72
INTRODUCTION
The temporoparietal fascia flap (TPFF) is the thinnest, most
pliable flap in the body, and can be used for moderate sized
defects of up to 12 × 14 cm. The TPFF is highly vascularized
and has a reliable arterial and venous pedicle. This flap’s
greatest strength is in its versatility, as it may carry hair-
bearing scalp, contain vascularized bone, or provide a thin
Temporoparietal
Fascia Flap
Steven L. Moran  |  Eric Santamaria
32 
covering for the ear or nose. The TPFF has gained greatest
recognition for its utility as a pedicled flap for ear and nasal
reconstruction and as a free flap in hand reconstruction.
This flap’s origins are evident in Monks and Brown’s
reports of eyelid and ear reconstruction,1,2 as well as Fox and
Edgerton’s description of the “fan flap” in 1976, which was
used as an adjunct for ear reconstruction.3 Harii et al. first
described the free scalp flap in 1974 as a free tissue transfer
for hair transplantation4; however, the first free microvascu­
lar transfer of the TPFF was described by Smith in 1980.5
Further reports by Brent, Upton, and others pointed to the
usefulness of this flap for coverage in the upper and lower
extremities.6–8 In 1986, Abul-Hassan et al. examined the
course of the superficial temporal artery and the middle
temporal artery with its course through the deep temporal
fascia.9 This work provided the anatomic basis for the devel­
opment of a two-layered flap consisting of both the TPFF
and deep temporal fascia.9,10 Since its original description,
several refinements have been made to the TPFF that have
included the incorporation of calvarial bone, temporalis
muscle, and hair-bearing scalp. Most recently, endoscopy
has been utilized for assistance in flap harvest.11 Though
flap dimensions are relatively small compared with newer
sources of vascularized fascia (i.e. lateral arm, serratus fascia,
and anterior lateral thigh fascia) and dissection is at times
tedious, the TPFF remains a valuable flap to have in one’s
armamentarium. Perhaps the main advantage of the TPFF
flap is that it leaves an almost inconspicuous donor site scar.
FLAP ANATOMY (Figs 32.1, 32.2 and see
Figs 10.1, 10.4, and 10.5)
The temporoparietal fascia (TPF) is the cephalad extension
of the superficial musculoaponeurotic system (SMAS) in the face.
The TPF is located in the temporal fossa, which is bounded
by the upper border of the zygoma, the supramastoid crest,
and the superior and inferior temporal lines. The floor of
the temporal fossa is composed of the temporal bone, pari­
etal bone, frontal bone, and the greater wing of the sphe­
noid. The pterion is the junctional point of these bones.
The scalp on top of the temporal fossa is itself a five-layered
structure (Fig. 32.3) (see also Ch. 10, and Fig. 10.2) the skin
and subcutaneous fat, which contains the hair follicles.
Immediately beneath this fat is the TPF, which comprises
the third layer of the scalp. At its superior margin, the TPF
continues cephalad as the galea aponeurotics. Anteriorly, the
Figure 32.1  Temporoparietal fascia flap.
Superficial
temporal
artery
Buccal branch
of facial nerve
Cervical branch
of facial nerve
Lesser
auricular
nerve
Deep temporal fascia
(overlies temporalis muscle)
Temporoparietal
fascia (cut)
Frontal branch
of facial nerve
Marginal mandibular
branch of facial nerve
Greater
auricular nerve
Zygomatic branch
of facial nerve
External carotid
artery
Internal carotid
artery
Posterior
occipital
artery
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION A  —  LOCAL AND FREE FLAPS IN THE HEAD AND NECK

CHAPTER 32 — Temporoparietal Fascia Flap
e73
Figure 32.2  (A) Regional anatomy of the temporoparietal area. The TPF fascia is a continuation of the SMAS. The TPF is also continuous
with the galea superiorly, frontalis muscle anteriorly, and occipitalis muscle posteriorly. The STA and vein arborize above the zygomatic arch
to give rise to an anterior and a posterior branch. The posterior branch may have connections with the posterior auricular artery and occipital
artery. (B) The TPF (also referred to as the superficial temporal fascia) and the deep temporal fascia are separate and distinct layers partitioned
by a loose areolar layer. The TPF has been divided at its superior margin and reflected inferiorly to show the deep temporal fascia. The deep
temporal fascia receives its blood supply from the middle temporal artery, a branch of the STA. (C) Clinical case showing the areolar layer, or
innominate fascia, as a separate vascularized layer that is located between the superficial and deep temporal fascia.
B
Galea
aponeurotica
Superficial
temporal
fascia
Frontalis
muscle
Superficial
temporal
artery and
vein
Temporal
branch of
facial nerve
Occipitalis
muscle
Parotid gland
Occipital
artery
Posterior
auricular
artery
A
Periosteum
Deep temporal
fascia
Middle temporal
artery and vein
Superficial temporal
fascia
Temporalis
muscle
C

e74
PART 4 — CONVENTIONAL WORKHORSE FLAPS
temporal arteries have been reported in patients with
hemifacial microsomia, Romberg’s hemifacial atrophy and
Treacher–Collins syndrome.15,16
At the zygomatic arch, the STA enters the superficial
temporal fascia. In 80% of cases, the STA bifurcates above
the zygomatic arch into anterior and posterior branches
(also known as frontal and parietal branches). In 5% of
cases, a large middle branch also may be present. Termi­
nally, the anterior branch of the STA supplies the frontalis
muscle. The posterior branch of the STA connects with the
branches of the occipital artery to supply the posterior scalp,
while the central (or parietal) branch supplies the parietal
scalp to the vertex.7,9,15,17
The middle temporal artery arises from the STA, at or just
superficial to the zygomatic arch. Immediately above the
zygomatic arch, the middle temporal artery enters the deep
temporal fascia. Harvesting the middle temporal artery with
the STA allows for the construction of a vascularized biped­
icled flap containing both the TPF and the deep temporal
fascia (Fig. 32.5).
Minor:  occipital artery
Length: 6.2 cm (range ± 3.5)
Diameter: 1.5 (range 0.6–2.0)
Identification of the occipital artery requires dissection
through a posterior auricular scalp incision. The vessel
arises posterior to the mastoid process and medial to the
longissimus and splenius capitis muscles. The pedicle is
identified underneath the semispinalis capitis muscle in a
horizontal and oblique course. The vein is reported to be
of similar caliber at this level though thin and friable.
Minor:  posterior auricular artery
Length: 6.4 cm (range ± 1.3 cm)
Diameter: 0.7–1.2 mm
The occipital and posterior auricular arteries are rarely
used to supply the flap. If the STA is not available or the arc
of rotation favors using these minor pedicles for recon­
structing a defect, the flap can be based posteriorly on these
vessels.
VENOUS DRAINAGE OF THE FLAP (Fig. 32.2 and
see Figs 10.4, 10.5)
Primary:  superficial temporal vein
Length: 3.4 cm (range 2.5–5 cm)
Diameter: 2.5 mm (range 2.1–3.3 mm, at the level of the
external auditory meatus)
Secondary:  occipital vein
Length: 6 cm
Diameter: 1.2–2.0 mm
Secondary:  posterior auricular vein
Diameter: 2.4 mm
Figure 32.3  Coronal section of the temporal fossa showing the
relation of the TPF to the scalp and deep temporal fascia. Note the
close proximity of the hair follicles to the TPF. The vessels are located
within or just external to the TPF fascia and thus may be inadvertently
injured during dissection. A loose areolar layer separates the TPF
from the deep temporal fascia.
Galea aponeurotica
Hair follicles
Temporal bone
Periosteum
Areolar space
Temporalis muscle
fascia
Temporalis muscle
Areolar tissue
Temporoparietal
fascia
Septa
Superficial temporal
artery and vein
Skin
Fat
TPF is continuous with the frontalis muscle and the occipi­
talis muscle posteriorly. Below the TPF lies a loose areolar
plane that separates the TPF from the deep temporal fascia,
which directly overlies the temporalis muscle; this areolar
layer has been referred to as the innominate fascia.12 The
deep temporal fascia continues superiorly over the tempo­
ralis muscle to become the periosteum overlying the tem­
poral bone.
ARTERIAL SUPPLY OF THE FLAP (Figs 32.1, 32.2,
32.4 and Figs 10.4, 10.5)
Dominant:  superficial temporal artery
Length: 3.4 cm (range 2.5–5 cm)
Diameter: 2.2 mm (range 1.8–2.7 mm, at the level of the
external auditory meatus)
The TPFF flap is considered a Type A fasciocutaneous flap,
with its direct cutaneous pedicle being the STA.13 Though
many authors report the STA to be consistently present,
Park et al. noted, in a study of 123 temporoparietal fascial
flaps, that 88.2% of flaps were supplied by the STA, while
8.6% were supplied by the posterior auricular artery and
3.2% were supplied by the occipital artery.14 A higher per­
centage of arterial anomalies and hypoplastic superficial

CHAPTER 32 — Temporoparietal Fascia Flap
e75
artery.7,15,17 The vein runs with the STA to its origin, where
the vein joins the maxillary vein to form the retromandibu­
lar vein, which drains into the external jugular vein.
FLAP INNERVATION (Fig. 32.6 and see Fig. 10.11)
The auriculotemporal nerve (ATN) arises from the third divi­
sion of the trigeminal nerve. It provides sensory innervation
of the auricle, external meatus, tympanic membrane, tem­
poromandibular joint, and temporal region. The nerve
passes behind the condylar process of the mandible and
then superiorly. At the level of the tragus, the ATN lies deep
to the STA. The nerve then moves superficially to lie super­
ficial to the STA at the level of the zygomatic arch. During
dissection, the auricular temporal nerve lies posterior to the
superficial temporal vessels and above the TPF and pro­
ceeds to innervate the temporal scalp.18 This nerve can be
used to provide sensory innervation to the flap.18
The zygomaticotemporal nerve also supplies sensation to the
anterior temporal area of the scalp; however, this area is not
routinely included in TPFF elevation due to its proximity to
the temporal branch of the fascial nerve.18
FLAP COMPONENTS
The flap may be transferred alone to provide vascularized
fascial coverage. The flap may also include the overlying
hair-bearing scalp, deep temporal fascia, temporalis muscle,
and outer table of the temporal bone.19 Inclusion of the
deep temporal fascia and temporalis muscle requires inclu­
sion of the middle temporal artery during dissection. The
Venous drainage of the TPFF is through the superficial
temporal vein in the majority of cases; however, venous
drainage has been reported to be less consistent than arte­
rial inflow patterns. In Park et al.’s study, only 63% of flaps
were drained mainly by the superficial temporal vein, while
the remainder were drained by the occipital or posterior
auricular veins.14,15 The superficial temporal vein usually lies
just anterior and superficial to the STA. However, it has been
reported that the vein can be as far as 3 cm away from the
Figure 32.5  Double-layered fascial flap utilizing both the TPF and
deep temporal fascia. The deep temporal fascia is supplied by the
middle temporal vessel branching from the STA just superior to the
zygomatic arch.
Figure 32.4  Five most common branching patterns of the superficial temporal artery. The most common pattern is seen in the center, where
the bifurcation of the STA occurs above the zygoma.

e76
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Finally, for auricular reconstruction, this flap has been
shown to provide superior long-term results for contouring
over cartilage grafts.14
DISADVANTAGES
The major limitation of the TPFF is its limited size
(12 × 14 cm), which makes the flap inadequate for larger
reconstructive problems. Other disadvantages include the
possibility of temporal nerve injury, alopecia, and the
tediousness of the upper scalp dissection. Alopecia at
the donor site is the result of damage to or destruction of
the hair follicles within the thin scalp flaps elevated during
flap harvest. Injury to the frontal branch of the facial nerve
is possible (Fig. 32.7). In some situations, the pedicle length
of the TPF free flap may be too short to reach the recipient
vessels and interpositional vein grafts may be required.
auriculotemporal is included in the flap harvest and thus
allows for the possibility of a sensate flap. The flap may also
be raised as a bipedicled flap (bucket handle flap) in which
both right and left TPF is harvested with inclusion of the
right and left vascular pedicles.
ADVANTAGES
The TPFF has several positive attributes, the first being a
relatively consistent arterial pedicle of large size (1.8–
2.2 mm) and sufficient pedicle length (4 cm).6 Two teams
may work simultaneously allowing for flap harvest and prep­
aration of the recipient site. The flap is versatile and may
be harvested as a composite flap with bone, in two layers,
or split longitudinally in line with arterial branches. This
flap may also provide a gliding surface for tendons. Most
donor site incisions are unperceivable following hair growth.
Figure 32.6  Anatomic course of the ATN and temporal branch of the facial nerve. The ATN runs superficial to the TPF while the temporal
branch of the facial nerve runs on the deep surface of the TPF.
Auriculotemporal
nerve
Temporal branch of facial
nerve
Skin
Fat
Temporoparietal
fascia
Areolar plane
Fascia of temporalis
muscle
Temporalis muscle
Auriculotemporal nerve
Skin
Fat
Temporoparietal
fascia
Areolar plane
Fascia of temporalis
muscle
Temporalis muscle
Temporal branch of
facial nerve
Skin
Fat
Temporoparietal
fascia
Parotid fascia
Parotid gland
VII
VII

CHAPTER 32 — Temporoparietal Fascia Flap
e77
the tragus. The STA usually bifurcates 2–4 cm superior to
the zygomatic arch, and may be identified with the hand­
held Doppler probe.
GENERAL THOUGHTS ABOUT FLAP DESIGN
The TPF is a thin and highly vascularized layer that lies
immediately beneath the hair follicles of the temporopari­
etal scalp. The TPF is progressively more adherent to the
subdermal fibro-fatty layer as it proceeds from the level of
the zygomatic arch cephalad toward the vertex of the skull.
Thus, dissection is started proximally at the level of the ear
where the planes are easiest to identify. The subdermal layer
of the scalp is also attached to the TPF by numerous small
vessels, making dissection tedious and potentially bloody, as
one moves more cephalad. The TPF is between 1.5 mm and
4 mm thick in children and can be as thick as 4.5 mm in
adults. Its expansion can be as large as 14 × 17 cm.17 Near
the lateral orbital rim, in the frontozygomatic area, the
frontal branch of the facial nerve lies on the deep surface
of the TPF. It is critical to be cognizant of the nerve’s course
in this area, so as to not injure it. A nerve stimulator may be
used to help localize the temporal branch if necessary. Trac­
tion on the underlying soft tissues in the area surrounding
the orbital rim can also produce a temporary traction neu­
ropraxia. The ATN, which is purely sensory, is invariably
incorporated within the flap.
FLAP DIMENSIONS
Flap dimensions are usually 14 × 12 cm, but may be extended
through preoperative tissue expansion or through harvest
FLAP DESIGN (Fig. 32.8)
ANATOMIC LANDMARKS
The flap may be centered on a line running from the pre-
tragal region to the vertex of the skull. The TPF is located
over the temporal fossa extending from the zygomatic arch
to the vertex. The STA is usually palpable just anterior to
Figure 32.7  This cadaver dissection shows the course of temporal
branch of facial nerve running just beneath the TPF (lower forceps).
Temporal branch lies inferior to the anterior branch of STA. Upper
forceps retracts the anterior edge of the TPF, allowing visualization
of the loose areolar layer lying immediately below.
Figure 32.8  Anatomic landmarks and flap design. Lateral aspect of the head. 1. Frontal. 2. Parietal. 3. Occipital. 4. Bregma (anterior fontanelle).
5. Lambda (posterior fontanelle). 6. Greater wing of sphenoid. 7. Squamous temporal. 8. Pterion. 9. Temporal lines. 10. Zygomatic arch. 11.
Mastoid process. 12. Styloid process. 13. Glabella. 14. External occipital protuberance. The scalp incision for flap dissection is designed as
an extension of the preauricular rhytidectomy incision. The initial incision is designed posterior to the STP vessels. The vessels can be identi­
fied with a handheld Doppler probe. A line between the pretragal region and the vertex marks the course of the superficial temporal artery.
The incision bifurcates into a Y 1–2 fingerbreadths above the upper pole of the ear. The vertical and anterior margins of the skin incision must
lie posterior and superior, respectively, to the frontal nerve branch. (B) Schematic representation of flap design for composite hair-bearing flap
(blue). The scalp component of the flap should be narrow enough to allow for primary closure, usually 2–4 cm in width, of donor site to avoid
skin grafting, though flaps as large as 6 × 35 cm have been transferred. Blue line marks incision for harvest of temporoparietal fascia flap without
skin. (From Standring S, ed. Gray’s anatomy. 40th ed. Elsevier, Churchill Livingstone; 2008.)
B
1
2
3
4
5
7
6
8
9
10
11
12
13
14
A
Margins of the
fascia flap
Superficial temporal
artery bifurcation
point, 2–4 cm
superior to the
zygomatic arch
Zygomatic arch
Vertex
Pretragal
region

e78
PART 4 — CONVENTIONAL WORKHORSE FLAPS
and vein, the TPFF may be passed beneath the zygomatic
arch into the oral cavity or into the nose.
FLAP MARKINGS (Figs 32.8, 32.9)
The course of the STA is first identified with a handheld
Doppler probe. Usually a T- or Y-shaped incision is marked
in the central portion of the temporal fossa to facilitate
of the contra lateral side as a bipedicled flap. An extended
skin island has been described over the occipital scalp based
on the posterior branch of the STA. The extended flap may
have dimensions of up to 25 × 4 cm.13
ROTATION OF PEDICLED FLAPS
Pedicled flaps are typically rotated or turned over at the
level of the zygomatic arch. If further islandized on the STA
Figure 32.9  (A) Flap dissection begins with identification of the STA and vein. Here the surgeon verifies that the caliber of the vessels will be
adequate for flap elevation. Elevation of the scalp flap begins inferiorly, where the plane between the dermis and superficial temporal fascia is
more easily identified. As dissection proceeds cephalad, separation becomes increasingly difficult secondary to the fibrous connections and
the perforating vessels from the superficial temporal artery to the overlying scalp. Anterior dissection is not carried below the level of the anterior
branch of the superficial temporal artery. Care is also taken to stay far enough posterior to avoid injuring the branches of the temporal nerve.
(B,C) Once the overlying skin has been freed from the TPF, the TPF is incised at its superior margin and elevated along with its pedicle in
retrograde fashion. The loose areolar plane deep to the TPFF is raised along with the flap rather expediently with visualization of the deep
temporal fascia below. (D) Dissection then proceeds to the major pedicle. Harvest of the deep temporal fascia requires preservation of the
perforating vessel, which is identified just inferior to the superior auricular margin. Once the vascular pedicle of the deep temporal fascia has
been identified, the fascia surrounding the muscle is elevated. Dissection of the main pedicle then proceeds to the base of the tragus.
A
B
C
D
Temporal branch
of facial nerve
Superficial
(temporoparietal)
fascia flap
Flap can be
split here
Deep temporal
fascia

CHAPTER 32 — Temporoparietal Fascia Flap
e79
After the scalp flaps have been elevated a template may be
made of the recipient site defect, and the template may be
applied to the TPFF. Anterior dissection is not carried below
the level of the anterior branch of the STA. Care is also taken
to stay far enough posterior, so as to not injury the branches
of the temporal nerve. The TPF is then incised and elevated
along with its pedicle in retrograde fashion. The loose areola
plane posterior to the TPFF is raised rather expediently, with
visualization of the deep temporal fascia below. Dissection
then proceeds to the major pedicle. Dissection is usually
stopped at the base of the tragus. Further dissection into the
parotid gland is not recommended, as injury to the facial
nerve may occur. Flap splitting may be carried out between
the major vascular branches of the STA, usually between the
central and posterior branch or anterior and posterior
branch if two smaller areas require coverage.20
Following pedicle division or flap rotation, the donor site
may be closed over a suction drain with deep subcuticular
sutures, followed by a running absorbable monofilament
sutures or staples (Fig. 32.10).
ENDOSCOPIC-ASSISTED HARVEST
The course of the STA is confirmed with the Doppler probe,
as in the open technique. Verification of the caliber of STA
and the vein is made through a preauricular incision. The
plane between the scalp and TPF is clearly established
through the preauricular incision. The dermis is then
injected overlying the scalp in the temporal area where the
flap will be harvested. Two 2–3 cm horizontal incisions are
made at the upper limits of the flap anteriorly and posteri­
orly, creating a triangle with the original preauricular inci­
sion. Through these incisions, a plane is created between
the scalp and TPF. The two incisions are then connected in
the subcutaneous plane. A 4 mm endoscope may then be
inserted through either the anterior or posterior incision,
depending on surgeon handedness, and dissection pro­
ceeds using the bipolar scissors. Multiple small perforating
veins and arteries to the scalp will be visualized and must be
the dissection and minimize undermining. Bifurcation of
this incision starts 3–4 cm above the superior margin of
the ear. The incision is usually started in the preauricular
region and then extended into the scalp in-line with the
STA.
PATIENT POSITIONING
The patient is placed supine. The head is supported on a
horseshoe surgical headrest in the lateral position. It is
important to be able to turn the head easily to the contra­
lateral side, should the flap artery or vein be insufficient for
free tissue transfer.
PREOPERATIVE PREPARATION
Imaging studies are not routinely performed prior to
surgery. After positioning the patient, the course of the STA
is marked with a handheld Doppler probe. The patient’s
hair does not need to be shaved; however, our preference
is to shave a small strip in the area of the marked incision.
The remaining hair is held back with elastic bands and
draped out of the field. A line is made between a point
5 mm below the tragus and 15 mm above the lateral eyebrow
to mark the presumed course of the frontal branch of the
facial nerve
ANESTHETIC CONSIDERATIONS
This flap should be harvested under general anesthetic with
a secure endotracheal tube. Additional local infiltration
with dilute epinephrine solution (1 : 200,000) is used over
the scalp to limit blood loss during flap harvest.
TECHNIQUE OF FLAP HARVEST (Fig. 32.9)
The TPF is initially exposed at the level of the ear through
a preauricular facelift incision, which is carried into the
hairline. This may be extended through the scalp in a T- or
Y-pattern; a zigzag pattern has also been described. Endo­
scopic assistance may also be used to limit the size of the
scalp incision and is discussed below.
The TPF lies immediately deep to the hair follicles in the
preauricular area. The superficial temporal vessels are iden­
tified and the surgeon verifies that the caliber of the vessels
is adequate for flap elevation. A 1 : 200,000 epinephrine
solution is now infiltrated into the area of the scalp to
control bleeding from the scalp flaps. Elevation of the scalp
flap begins inferiorly where the plane between the dermis
and superficial temporal fascia is more easily identified. We
prefer to use a handheld battery-powered coagulator, or a
needle-point coagulator set at a relatively low setting to
prevent transmitted thermal injury to the hair follicles in
this area. Damage to the hair follicles may result in postop­
erative alopecia. As dissection proceeds, cephalad separa­
tion becomes increasingly difficult secondary to the fibrous
connections and the perforating vessels from the superficial
temporal artery to the overlying scalp. Meticulous hemosta­
sis is required. Counter-traction of the scalp by an assistant
significantly facilitates dissection.
Figure 32.10  Scalp flaps are closed with a combination of absorb­
able monofilament sutures and staples.

e80
PART 4 — CONVENTIONAL WORKHORSE FLAPS
cauterized to maintain an adequate optical field. When the
superior dissection is completed, the posterior and anterior
margins of the TPF are incised. Suture may be placed on
the superior margin of the flap and passed endoscopically
out the preauricular incision. Dissection of the deeper layer
is performed quickly with the use of a blunt surgical eleva­
tor. The flap may then be passed through the preauricular
incision.11,21
It should be noted that there is a significant learning
curve with this technique and initial flap harvests have been
reported as long as 2–2.5 h.11,21 Additional incisions may be
required should bleeding occur during dissection. This
technique should be reserved for surgeons already familiar
with the open technique.
FLAP MODIFICATIONS
BILOBED: TPFF WITH DEEP TEMPORAL FASCIA
A bilobed flap may be created when two gliding planes are
required. The deep temporal fascia is a dense semicircular
fascia, which is closely adherent to the temporalis muscle.
At each margin, this fascia ends in periosteal attachments
at the frontal and parietal bones and at the upper edge of
the zygomatic arch. Maximum dimensions in an adult are
usually 7 × 7 cm.
The deep temporal fascia is lifted off the underlying tem­
poralis muscle and separated from its zygomatic attach­
ments. The middle temporal vessel is preserved with the
STA just superior to the zygomatic arch. The double-leaf
arrangement of this flap is ideal for tendon reconstruction
when there is injury to both the bony metacarpal surface of
the dorsum of the hand. This flap may also be used in a
pedicled fashion for reconstruction of the temporal man­
dibular joint, resurfacing of the bony orbit, or for resurfac­
ing the lateral aspect of the nose.9,10
TEMPORAL CALVAREAL OSTEOFASCIAL FLAP
The outer table of the temporal bone may be included with
the TPFF. The outer table is harvested as a split graft. A burr
is used to outline the graft area and osteotomes are then
used to complete the harvest. A generous cuff of fascia and
pericranium must be preserved at the margins of the graft.
Care must be taken to incorporate all layers of the galea at
the superficial margin of the deep temporal fascia, as this
holds the major arterial perforators to the bone.19 To
prevent shearing of the deep surface of the galea and the
bone, sutures are placed through drill holes at the periph­
ery of the bone. On its superficial surface, where the galea
is densely adhered to the scalp, dissection is fairly tedious
to prevent exposing hair follicles. Flap dissection then pro­
ceeds normally to completion.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATIONS
1. Start dissection in the preauricular area and clearly
define the arterial pedicle and venous pedicle. The vein
does not consistently run immediately next to the artery
and may be as far as 3 cm away from the STA. The vein
lies superficial to the fascia and may be injured if care is
not taken during the first portion of the dissection. If
either vessel is not clearly identified and a free flap is
planned, it is then recommended to turn the head and
explore the contralateral preauricular region for a suit­
able pedicle. If a pedicled flap is planned and the STA
or STV is not clearly identified, the flap may still be raised
on the posterior auricular vessels, or the occipital vessels
in some cases.14
2. Identify the plane between the TPF and dermis at the
preauricular level. Dissection then proceeds superiorly
toward the vertex. Beginning the dissection over the tem­
poral fossa risks perforating the fascia and may compro­
mise flap success.
3. Remember that the temporal branch of the facial nerve
typically lies along a line 5 mm below the tragus and
15 mm above the lateral eyebrow. This line is often
marked on the patient to remind the surgeon to be cau­
tious during dissection in this area, in order to avoid
neuropraxia or permanent injury to the temporal branch
of the facial nerve (Fig. 32.4).
4. Redundant scalp at the completion of the case can be
excised at their leading edge as this is the area most likely
to become devascularized resulting in postoperative
alopecia.
5. For a thinner facial flap and to enhance cartilage defi­
nition in auricular reconstruction, Park and colleagues
emphasized the exclusion of the subcutaneous fat and
the intentional deinnervation of the superior auricular
muscle, which may be occasionally seen within the tem­
poroparietal fascia. This muscle is innervated through
small branches arising from the temporal branch of the
facial nerve and posteriorly from the posterior auricular
nerve.14 Additionally, an innominate layer is present
between the TPFF and the deep temporal facial, which
can be left in place during the harvest to reduce thick­
ness of the flap.
FLAP USAGE
PEDICLED FLAP
This flap has been extensively described as a means of cover­
ing the ear in cases of trauma and microtia reconstruc­
tion.3,7,14,16,22,23 Multiple reports also note its utility in orbital,
facial, and maxillary reconstruction.3,7,14,16,24,25 Composite
pedicled osseous-TPF flaps have been described for the
closure of palatal fistulas.26,27 Hair-bearing flaps have also
been described for upper lip and scalp reconstruction.28
FREE FLAP
The flap may be utilized as a free flap in any case requiring
thin but durable coverage (see Case examples, below). It
has gained greatest recognition for its capabilities in recon­
structing dorsal hand defects, where its fascial surface pro­
vides an excellent surface for tendon gliding. This flap has
been described to cover post-traumatic ear reconstruction,
burns, large nasal reconstructions, lower extremity defects,
and cases of extremity osteomyeleits.5–8,10,22,29

CHAPTER 32 — Temporoparietal Fascia Flap
e81
the flap or division of the pedicle in cases of free tissue
transfer. Areas at the periphery of the flap, especially in the
watershed zones between the STA and occipital artery, may
be trimmed prior to flap transfer if bleeding is not appreci­
ated once the flap is islandized. Venous insufficiency may
not always be appreciable at the time of insetting. Conges­
tion within the flap is often difficult to appreciate if the flap
is immediately covered with an unmeshed skin graft. For
such cases, we recommend implantable Doppler probes on
the vein, which will alert the surgeon to signs of impending
venous congestion or thrombosis. Due to the thinness of the
superficial temporal veins, care should be taken when han­
dling these vessels in order to avoid intimal injury.
Though few large series studying this flap exist, the inci­
dence of total flap loss has ranged from 1.8–8%, partial flap
loss in pedicled cases has been noted at 4.5–8%. Frontal
nerve paralysis has been noted to range from 1–20%.8,11,14
Permanent alopecia rates have also been noted to range at
0–20%. Postoperative alopecia may be avoided by deepen­
ing the dissection and not exposing hair follicles, while
raising the flap.
CONCLUSIONS
The temporoparietal fascia provides a versatile source of
thin pliable tissue for multiple defects throughout the head
and neck and extremities. The TPFF is ideal for providing
non-bulky covering to medium and small areas. The flap
may be raised as a composite flap incorporating hair-bearing
scalp or bone. The pedicle is of adequate length and diam­
eter for free tissue transfer, and its harvest site often allows
two teams to work simultaneously during larger cases. The
donor site is inconspicuous providing a major benefit over
other cutaneous free flaps. The flap remains an important
tool for the reconstructive and microsurgeon.
ATYPICAL
Upton et al. described the use of prelaminated TPF flaps
for cases of complex oral and nasal cavity reconstruction.30
These prelaminated flaps are created in two stages, with the
first stage involving the placement of a skin graft on top of
the TPF to create an epithelial lining. The skin graft is then
allowed to mature for 3–4 weeks and then it may be trans­
ferred as a pedicled epithelialized island flap to the nose or
oral cavity. Free tissue transfer may also be used for more
distant defects. Flap survival in this series was 100%.30 The
TPFF has also been described as a pedicle flap for the
closure of pharyngocutaneous fistulas.31
POSTOPERATIVE CARE
Our postoperative protocol for free flap monitoring involves
hourly Doppler checks of the pedicle for 24 h following
surgery. Vascular exams are then gradually tapered over the
next 24–48 h. Buried Doppler probes may also be used to
enhance flap monitoring.
Pedicled flaps are usually discharged on postoperative
day 1. Most free tissue reconstructions leave the hospital in
5 days. Scalp drains may often be removed in 48–72 h. We
allow protected motion of reconstructed tendons beneath
TPFF flaps 72 h following reconstruction.
UNTOWARD OUTCOMES
Major complications include total, partial flap loss, perma­
nent temporal nerve injury, and permanent alopecia over
the temporal fossa. Signs of impending flap or partial flap
loss have been noted in some case series prior to insetting.
A common finding in these reports is the inability to appre­
ciate active bleeding from the flap edges prior to pedicling

e82
PART 4 — CONVENTIONAL WORKHORSE FLAPS
CASE 32.1  Dorsal Hand Injury Reconstructed with a Free TPF Flap and a Skin Graft
Figure 32.11  (A). Crushed injury with extensive soft tissue/skin necrosis with exposed tendons, due to a motor vehicle accident. (B) After
extensive debridement, a 12 × 14 cm defect with exposed extensor tendons and metacarpal bones is observed. (C) In preparation of the
TPF free flap, a Y-shaped incision is designed after trimming only the hairy skin to be incised (Hair trimming is not necessary). (D) Flap
elevated on vascular pedicle prior to division. (E) TPF free flap after its pedicle division. (F) Flap inset over exposed metacarpal bones and
extensor tendons. (G) TPF free flap after completing vascular anastomoses to the cephalic vein and princeps pollicis artery in an end-to-
end fashion. Note extension of the TPF flap to cover the dorsal aspect of the index finger. (H) The TPF was covered by a split-thickness
skin graft. Early postoperative outcome showing an adequate skin graft taking and mild color mismatch. (I) Lateral view of the TPFF
showing perfect contour and minimal bulk, which allows complete finger flexion and extension and normal gliding mechanism of the
tendons.
A 31-year-old man suffered a motor-vehicle accident and pre-
sented with a degloving injury to the dorsum of the hand
with exposed extensor tendons and metacarpal bones. After
extensive necrotic tissue debridement, immediate soft tissue
coverage was provided with a TPFF flap and a split-thickness skin
graft from the thigh. The patient recovered the complete range
of extensors function uneventfully, with inconspicuous donor
site scars.
A
D
G
B
C
E
H
F
I

CHAPTER 32 — Temporoparietal Fascia Flap
e83
A young man with microtia underwent autologous ear recon-
struction with rib cartilage. In a second-stage procedure, he
had cartilage to the postauricular area to provide projection. A
temporoparietal flap was used to cover the cartilage. A skin graft
was placed on top of the TPF. The patient has a reasonable
reconstruction of his congenital deformity.
CASE 32.2  Microtia Reconstructed with Autologous Rib Cartilage, a Pedicled TPF Flap,
and Skin Grafting
Figure 32.12  (A,B) Pre- and postoperative photographs of first-stage auricular reconstruction. (C,D) Design and harvesting of the tem­
poroparietal fascial flap at second-stage auricular reconstruction. (E,F) The TPF flap is turned over 180° to cover the raw surface of the
cartilage auricular framework at the time of elevation and creation of the new retroauricular sulcus. (G,H) A skin graft is sutured on top of
the TPF flap and is covered with a tie-over during 5 days. (I) Postoperative result 6 months after total auricular reconstruction. Please note
donor scar of the TPF flap, which can be covered with the hair.
A
D
E
G
H
I
F
B
C

e84
PART 4 — CONVENTIONAL WORKHORSE FLAPS
A 25-year-old man suffered a handgun injury to the left hand
resulting in a large blast injury to the dorsum of hand with
destruction of distal carpal row, extensor tendons, and skin. The
carpal injury was treated with iliac crest bone grafting and
tendon grafts were performed. A TPFF was harvested to provide
a thin gliding surface for tendon motion, while providing a
durable soft tissue covering. The TPFF was covered with a non-
meshed split-thickness graft
CASE 32.3  Dorsal Hand Defect Reconstructed with a Free TPF Flap and a Skin Graft
Figure 32.13  (A) Anteroposterior radiograph of the hand showing significant carpal bone loss. (B) Soft tissue injury due to handgun injury
with loss of skin and extensor tendons. (C) Flap elevation with TPFF folded back to reveal loose areolar plane. (D) Flap elevated on vascular
pedicle prior to division. (E) Flap inset over bone graft and tendon grafts. (F) Lateral view of the TPFF emphasizing the superior contour
and minimal bulk that is provided with the use of this flap. (G) Flap is covered with unmeshed split-thickness skin graft.
A
B
C
D
E
F
G

CHAPTER 32 — Temporoparietal Fascia Flap
e85
A 22-year-old woman suffered a degloving accident of the foot
after a lawnmower accident. Extensor tendons remained intact.
Coverage was provided with a TPFF flap covered with an
unmeshed full-thickness graft taken from the abdomen. The
patient regained full foot function and was wearing normal foot-
wear in 6 months.
CASE 32.4  Dorsal Foot Defect Reconstructed with a Free TPF Flap and a Skin Graft
Figure 32.14  (A) Dorsal degloving injury of foot with intact extensor tendons. (B) Intraoperative photograph with flap elevated, again
emphasizing the thin but durable qualities of the flap. (C) Flap is transferred to the foot and covered with a full-thickness graft.
A
B
C
Expert Commentary 
Zung-Chung Chen, MD
The temporoparietal fascia flap (TPF) and the deep temporal
fascia (DTF) are commonly used as pedicled flaps in auricular
reconstruction. Uncommonly, they are used as free flaps for the
same purpose. The TPF is used to cover the cartilage block used
to project the ear, in ear reconstruction using autologous carti-
lage. It provides wide, pliable thin fascia tissue, which can cover
not only the posterior surface of the projected auricle but also the
helical rim. This flap allows us to treat situations when the hair
over the reconstructed ear is an issue, to provide a delicate profile
to the helical rim, and possibly further augment the blood supply
of the reconstructed auricle. Although not proven scientifically, we
believe the robust blood supply provided by the TPF helps provide
a better chance for a long-term stable outcome. The TPF also
provides good coverage in cases with a low hairline (after epilation
surgery), cases with local scarring resulting from trauma, or iat-
rogenic causes in secondary auricular reconstruction and, in not
so common situations, tissue coverage in rescue procedures. The
TPF also provides the tissue necessary in a one-stage operation
when using costal cartilage grafts or implants. In these cases,
coverage with a TPF offers the opportunity to achieve a good
result. Satisfactory results come from adequate soft tissue cover-
age, and a tension-free coverage, especially when an implant is
used for ear reconstruction. Moreover, high-quality skin coverage
is so important above the TPF, without superb quality skin cover-
age, excellent results can never be achieved. This is also true for
other areas of reconstruction when we consider TPF coverage.
When possible, we prefer to avoid incisions in the scalp by
approaching the TPF harvest through the incision created along
the outer margin of auricle (along where the helical rim would be).
Using this approach, up to 11 × 12 cm TPF can be raised in the
pediatric patient or even in adult patients, without endoscopic
assistance. Since there is no hair along this type of incision, alo-
pecia is not a concern. Placing a drain is not generally required
but can be helpful in cases when there is significant oozing
throughout the case. The deep temporal fascia can be utilized
when the TPF is not available, for anterior surface coverage or for
projection surgery. It can be thin and reliable and can include
periosteum beyond the margin of the temporalis muscle to
increase the length. The dimensions of the deep temporal fascia
cannot be as long and wide as the TPF.
REFERENCES
1. Monks GH. The restoration of a new lower lid by a new method.
Boston Med Surg 1898;139:385.
2. Brown WJ. Extraordinary case of horse bite: the external ear
completely bitten off and successfully replaced. Lancet 1898;1:
1533.
3. Fox JW, Edgerton MT. The fan flap: an adjunct to ear reconstruc­
tion. Plast Reconstr Surg 1976;58:663.
4. Harii K, Omori K, Omori S. Hair transplantation with free scalp
flaps. Plast Reconstr Surg 1974;53(4):410–13.
5. Smith RA. The free fascial scalp flap. Plast Reconstr Surg 1980;
66(2):204–9.
6. Upton J, Rogers C, Durham-Smith G, et al. Clinical applications of
free temporoparietal flaps in hand reconstruction. J Hand Surg
1986;11A:475–83.
7. Brent B, Upton J, Acland RD, et al. Experience with the temporo­
parietal fascial free flap. Plast Reconstr Surg 1985;76:177–88.
8. Hing DN, Buncke HJ, Alpert BS. Use of the temporoparietal free
fascial flap in the upper extremity. Plast Reconstr Surg 1988;81:
534–44.
9. Abul-Hassan HS, von Drasek Ascher G, Acland RD. Surgical
anatomy and blood supply of the fascial layers of the temporal
region. Plast Reconstr Surg 1986;77:17–24.
10. Biswas G, Lohani I, Chari PS. The sandwich temporoparietal free
fascial flap for tendon gliding. Plast Reconstr Surg 2001;108:
1639–45.
11. Yano H, Fukui M, Yamada K, et al. Endoscopic harvest of free
temporoparietal fascial flap to improve donor-site morbidity. Plast
Reconstr Surg 2001;107:1003–8.
12. Casanova R, Cavalcante D, Grotting JC, et al. Anatomic basis for
vascularized outer table calvarial bone flaps. Plast Reconstr Surg
1986;78:300.
13. Mathes SJ, Nahai F. Temporoparietal fascia flap. In: Mathes SJ,
Nahai F, editors. Reconstructive surgery: principles, anatomy and
technique. New York: Churchill Livingstone; 1997. p. 367–84.

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24. Horowitz JH, Persing JA, Nichter LS, et al. Galeal-pericranial flaps
in head and neck reconstruction: anatomy and application. Am J
Surg 1984;148:489.
25. Choung P, Nam I, Kim K. Vascularized cranial bone grafts for
mandibular and maxillary reconstruction. The parietal osteofascial
flap. J Cranio-Max Fac Surg 1991;19:235–42.
26. Furnas DW. Temporal osteocutaneous island flaps for complete
reconstruction of cleft palate defects. Scand J Plast Reconstr Surg
1987;21:119–28.
27. Choung P. The auriculomastoid fasciocutaneous island flap: a new
flap for orofacial reconstruction. J Oral Maxillofac Surg 1996;54:
559–67.
28. Kim JC, Hadlock T, Varvares MA, et al. Hair bearing temporopari­
etal fascial flap reconstruction of upper lip and scalp defects. Arch
Facial Plast Surg 2001;3:170–7.
29. Lai A, Cheney ML. Temporoparietal fascial flap in orbital recon­
struction. Arch Facial Plast Surg 2000;2:196–201.
30. Upton J, Ferraro N, Healy G, et al. The use of prefabricated fascial
flaps for lining of the oral and nasal cavities. Plast Reconstr Surg
1994;94:573–9.
31. Fabrizio T, Donati V, Nava M. Repair of the pharyngocutaneous
fistula with fasciocutaneous island flap pedicled on the superficial
temporalis artery. Plast Reconstr Surg 2000;106:1573–6.
14. Park C, Lew D, Yoo W. An analysis of 123 temporoparietal fascial
flaps: anatomic and clinical considerations in total auricular recon­
struction. Plast Reconstr Surg 1999;104:1295–306.
15. Upton J. Surgical anatomy and blood supply of the fascial layers
of the temporal region (discussion). Plast Reconstr Surg 1986;77:
25–8.
16. Tegtmeier RE, Gooding RA. The use of a fascial flap in ear recon­
struction. Plast Reconstr Surg 1977;60:406.
17. Strauch B, Yu HL, editors. Temporoparietal fascia. In: Atlas of
microvascular surgery: anatomy and operative approaches. New
York: Thieme; 1993. p. 526–33.
18. David SK, Cheney ML. An anatomic study of the temporoparietal
fascial flap. Arch Otolaryngol Head Neck Surg 1995;121:1153–6.
19. Cutting CB, McCarthy JG, Berenstein A. Blood supply of the upper
craniofacial skeleton: the search for composite calvarial bone flaps.
Plast Reconstr Surg 1984;74:603.
20. Chowdary RP. Use of temporoparietal fascia free flap in digital
reconstruction. Ann Plast Surg 1989;23:543–6.
21. Takushima A, Asato H, Harii K. Endoscopic-assisted harvest of the
temporoparietal fascial flap. Ann Plast Surg 2000;45:382–5.
22. Park C, Roh TS. Total ear reconstruction in the devascularized
temporoparietal region: I. Use of the contralateral temporoparietal
fascial free flap. Plast Reconstr Surg 2001;108:1145–53.
23. Brent B, Byrd HS. Secondary ear reconstruction with cartilage
grafts covered by axial, random, free flaps of temporoparietal
fascia. Plast Reconstr Surg 1983;72:141.

387
Supraclavicular Artery Flap
Michael R. Zenn 33 
INTRODUCTION
The supraclavicular flap was reported first by Lamberty in
1979. The flap was not reported on further until Pallua
reported its use in cases of neck contracture reconstruction
in 1997. Since that time, the flap has been widely used and
reported on. The supraclavicular flap has been favored for
head and neck reconstruction due to its match with color
and texture of the recipient head and neck skin. The supra­
clavicular flap has been described for resurfacing the neck
in cases of contracture and resurfacing the face in cases of
burns, sternal reconstruction, tracheal-stomal reconstruc­
tion, esophageal reconstruction, facial recontouring, and
more.
The supraclavicular flap is a fasciocutaneous flap that
occupies the area around the clavicle that extends over the
deltoid muscle. It is similar to the area utilized in an
extended deltopectoral flap. Since the vascular pedicle lies
above the clavicle, it has a better arc of rotation to the head
and neck area than the deltopectoral flap and can often be
closed primarily. For uses below the clavicle, the deltopec­
toral flap may be preferred. The average width of the flap
that can be closed primarily is 7 cm, and the flap is reliable
without a vascular delay to level of the insertion of the
deltoid over the humerus. Because of its location over the
clavicle and chest, it is commonly used with tissue expan­
sion, which allows stable expansion of the skin and easy
donor site closure.
FLAP ANATOMY (Figs 33.1 and 11.1)
ARTERIAL SUPPLY OF THE FLAP
Dominant:  supraclavicular artery
Length: 7 cm (range 1–7 cm)
Diameter: 1–1.5 mm
The supraclavicular artery is a branch of the transverse
cervical artery (Fig. 33.1). The transverse cervical artery
arises from the thyrocervical trunk. The thyrocervical trunk
comes off the first portion of the subclavian artery, located
distal to the vertebral artery takeoff and proximal to the
costocervical trunk. The branches of the thyrocervical trunk
include the inferior thyroid artery, the suprascapular artery,
the ascending cervical artery, and the transverse cervical
artery. The transverse cervical artery runs laterally in front
of the anterior scalene muscle to supply the flap.
The artery runs axially through the flap for an average of
7 cm in length. The vessel only has a diameter of 1–1.5 mm
at the origin. The supraclavicular artery can be found within
the triangle composed of the sternocleidomastoid muscle
anteriorly, the clavicle inferiorly, and the trapezius muscle,
posteriorly (Fig. 33.2). Within this triangle the vessel is ante­
rior to the external jugular vein when identifiable. The
artery can also be found relative to other landmarks: 8 cm
lateral to the sternoclavicular joint, 2 cm posterior to the
sternocleidomastoid muscle, and 3 cm above the clavicle.
Supraclavicular
artery
Deltoid
Sternocleidomastoid
Transverse cervical artery
Subclavian artery
Thyrocervical trunk
Trapezius
Pectoralis major
Axillary artery
Medial branch of
supraclavicular nerve
Intermediate branch
of supraclavicular nerve
Lateral branch
of supraclavicular
nerve
Suprascapular
artery
Common
carotid artery
Vertebral artery
Inferior thyroid
artery
Ascending
cervical artery
Figure 33.1  Supraclavicular flap.
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION B  —  LOCAL AND FREE FLAPS IN THE CHEST

388
PART 4 — CONVENTIONAL WORKHORSE FLAPS
of the upper and posterior shoulder and supplies the acro­
mial clavicular joint area.
FLAP COMPONENTS
The supraclavicular flap can be harvested as a pedicled
fasciocutaneous flap or as a free flap. The flap is most com­
monly used as a pedicled flap. Flap provides thin skin with
thin subcutaneous fat and fascia.
ADVANTAGES
• The vascular supply is reliable and consistent.
• This supraclavicular artery is usually not disrupted after a
modified radical neck dissection, commonly encountered
in head and neck cancer patients.
• The color and texture of the supraclavicular area
match the color and texture of non–hair-bearing facial
skin.
• Its use as a pedicle flap does not require expertise in
microsurgery.
• Morbidity is limited as no muscle is taken with the flap
and no critical nerves are sacrificed.
• Primary closure of the donor site may be obtained with
flap widths of ≤7 cm.
• Large amounts of tissue can be generated using this flap
combined with tissue expansion.
• Harvest is rapid and straightforward. Identification of the
primary pedicle is not required to elevate and use this
flap.
• With preservation of the supraclavicular nerves, this flap
can be sensate.
DISADVANTAGES
• The blood supply to this flap may not be available due to
previous surgery or radiation. CT angiography or MRA
can be performed preoperatively to confirm vessel
patency.
• The length of this flap may be limited beyond the numeral
insertion of the deltoid without surgical delay.
• Flap width of >7 cm may require skin grafting.
• The flap does not provide hair-bearing skin for lower
facial and neck reconstruction in men.
PREOPERATIVE PREPARATION
All patients should be examined before raising the flap. Any
neck scars or deformities that might interfere with the vas­
cularity or the design of the flap should be noted. The
contralateral supraclavicular area should also be examined
as an alternative to the ipsilateral flap.
The supraclavicular flap can be performed in patients of
all ages and in both sexes. There may be some distortion of
the breast in female patients, depending on skin laxity and
the size of the flap harvested. In obese patients, excessively
thick subcutaneous tissue may make the supraclavicular flap
unsuitable for reconstruction of some defects.
Medical comorbidities generally do not limit the utiliza­
tion of this flap. However, medical comorbidities such
VENOUS DRAINAGE OF THE FLAP
Primary:  the vena comitantes accompanying the arteries
Length: 7 cm (range 1–7 cm)
Diameter: 2.5 mm at its origin
Venous drainage from the supraclavicular region includes
both the external jugular vein laterally and the internal
jugular vein centrally. Once elevated, the flap drains primar­
ily to the internal jugular system.
Venous drainage parallels the arterial supply of the flap
via vena comitantes that run with the supraclavicular artery.
These comitantes drain into the transverse cervical veins
that ultimately join the internal jugular vein.
FLAP INNERVATION
Sensory:  the supraclavicular nerves (C3, C4)
Motor:  none
The supraclavicular nerves derive from the C3 and C4
nerve root and supply the supraclavicular area extending
beyond the clavicle on to the anterior chest. They emerge
from beneath the posterior border of the sternocleidomas­
toid muscle and descend into the posterior triangle of the
neck beneath the platysma and the deep cervical fascia. It
is near the clavicle that they perforate the fascia and the
platysma to become cutaneous.
The supraclavicular nerve has three distinct branches: the
medial branch, the middle branch, and the lateral branch.
The medial branch crosses obliquely over the external
jugular vein and the clavicular and sternal head of the ster­
nocleidomastoid muscle. This supplies the skin as far as the
midline and supplies the area of the sternoclavicular joint.
The middle branch crosses the clavicle and supplies the skin
over the pectoralis major and deltoid muscles, communicat­
ing with the cutaneous branches of the upper inner costal
nerves. The lateral branch passes obliquely across the outer
surface of the trapezius and the acromion to supply the skin
Figure 33.2  Cadaveric dissection of supraclavicular flap. Latex
injection shows the supraclavicular artery emanating from the triangle
bounded by the SCM, trapezius, and clavicle. Note the axial nature
of the vessel within the flap.