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Nasal Reconstruction with Free Tissue Transfer Assisted by “Delay”

Economides, Nicholas G. M.D., Ph.D.

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Plastic and Reconstructive Surgery: April 2012 - Volume 129 - Issue 4 - p 723e-724e
doi: 10.1097/PRS.0b013e318245e721
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I very much enjoyed the article “Microvascular Repair of Heminasal, Subtotal, and Total Nasal Defects with a Folded Radial Forearm Flap and a Full-Thickness Forehead Flap,” by Drs. Frederick Menick and Arthur Salibian (Plast Reconstr Surg. 2010;127:637–651).1 The authors used a radial forearm free flap for various degrees of nasal reconstruction, using the temporal artery and the external jugular vein and/or the facial vessels. There were 13 cases with similar defects, although none was secondary to a burn.

I am taking the liberty to share with you a case that occurred in 1986. The absence of the nose was the result of third-degree burns, and the deformity had affected the availability of suitable vascular access.

The procedure was performed in three stages. During the first operation, we raised a nasally shaped radial forearm flap, and skin grafted the back side with a split graft. We left it attached as a “delay” (Fig. 1, below).

Fig. 1
Fig. 1:
(Above) Final appearance of the free radial forearm flap designed in nasal configuration. (Below) Neonasal flap before separation.

When the viability and take were ensured, we proceeded with a second procedure, where we created a microvascular access by forming a 10-cm loop as an arteriovenous fistula connected to the left temporal artery, thus bypassing all the scarring. During the third procedure, we separated the nasal substitute from the forearm (Fig. 1, above), divided the arteriovenous fistula, and performed the microvascular anastomoses accordingly. The flap was set in by suturing the grafted side to mucosa and the radial flap to the surrounding skin (Fig. 2).

Fig. 2
Fig. 2:
Free flap on nasal defect following revascularization.

The case was never reported, primarily because the flap underwent severe congestion, resulting in epidermolysis and very significant tissue loss. I was on the faculty of the University of Tennessee at the time. The case remained in my files all these years; I had not seen another case in private practice in which this flap could have been used.

The authors need to be congratulated for their contribution. Their cases are unique and the solutions were successful and complex. It needs to be pointed out that a complete external nasal structure can be formed in the forearm over a period of time, one that carries all the components, including mucosa, cartilage, and bone. Ample time is needed before the eventual transfer.2

Nicholas G. Economides, M.D., Ph.D.

Department of Plastic Surgery, Ohio University, at Holzer Clinic, Athens, Ohio


1. Menick F, Salibian A. Microvascular repair of heminasal, subtotal, and total nasal defects with a folded radial forearm flap and a full-thickness forehead flap. Plast Reconstr Surg. 2011;127:637–651.
2. Atisha D, Alderman AK, Janiga T, Singal B, Wilkins EG. The efficacy of the surgical delay procedure in pedicle TRAM breast reconstruction. Ann Plast Surg. 2009;63:383–388.


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