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Angular Artery Perforator Flap for Reconstruction of Nasal Sidewall and Medial Canthal Defects

Brunetti, Beniamino M.D.; Tenna, Stefania M.D., Ph.D.; Aveta, Achille M.D.; Segreto, Francesco M.D.; Persichetti, Paolo M.D., Ph.D.

Plastic and Reconstructive Surgery: October 2012 - Volume 130 - Issue 4 - p 627e–628e
doi: 10.1097/PRS.0b013e318262f6ac

Plastic and Reconstructive Surgery Unit, Campus Bio-Medico of Rome University, Rome, Italy

Correspondence to Dr. Tenna, Plastic and Reconstructive Surgery Unit, Campus Bio-Medico of Rome University, Via Alvaro del Portillo, 200, 00128 Rome, Italy

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Facial artery perforator flaps have been popularized for reconstruction of perioral, perinasal, and nasal defects,1,2 but to date the clinical use of angular artery perforator flaps has never been reported. In 1996, Fabrizio et al.3 first introduced the retroangular flap into clinical practice, describing it as a reverse flow fasciocutaneous axial flap based on the distal communications of the angular artery with the contralateral one and the supraorbital artery. Since then, many other studies have shown the reliability of this flap for midface reconstruction.4,5 The original technique required the harvesting of fascia and, occasionally, of some fibers from the levator labii superioris muscle to allow a safer inclusion of the main pedicle within the flap. The authors report their initial experience with the use of the angular artery perforator flap in nasal reconstruction. In the past 2 years, they have developed the above-mentioned technique, converting the retroangular flap into the angular artery perforator flap. Five patients (four women and one man), aged between 56 and 83 years (mean, 67 years), were treated with the angular artery perforator flap. All of the wounds resulted from prior basal cell3 or squamous cell2 carcinoma excision and involved ipsilateral nasal sidewall and/or medial canthal subunits. A Doppler probe was used to localize the angular artery and its perforators along the nasolabial fold. The flap was subsequently drawn in a triangular fashion to obtain primary closure of the donor site by means of V-Y advancement (Fig. 1). The flaps were harvested under local anesthesia and with the aid of 2.5× loupe magnification. Dissection started at the medial margin of the flap lying in the nasolabial fold. This approach allowed a wide exposure of the underlying structures and the chance to convert the procedure to a classic random subcutaneous pedicle V-Y flap in the event of unreliable or damaged perforators. One or two perforators were usually found during dissection, more commonly close to the medial margin of the flap, where the source vessel resides (Fig. 2). Once the perforators were isolated, they were gently freed from fibrous attachments to the levator labii superioris and levator labii superioris alaeque nasi muscles and the flap was subsequently islanded on the selected perforators. An extended dissection of the vessels was avoided, as an adequate advancement of the flap was always achieved without the need to trace the perforators to their source vessel. Temporary venous insufficiency was a common postoperative finding, especially in case of single perforator pedicled flaps. All of our flaps healed successfully and the patients were satisfied with the aesthetic result (Fig. 1). Our limited experience showed the reliability of the angular artery perforator flap in case of reconstruction of small to moderate size defects involving medial canthal and upper nasal sidewalls subunits. We encourage others to conduct more cadaveric and clinical studies to improve flap harvesting and better define its clinical indications in the setting of facial reconstructive surgery.

Fig. 1

Fig. 1

Fig. 2

Fig. 2

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The patient provided written consent for use of her images.

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The authors have no commercial associations that might pose or create a conflict of interest with information presented in this article. No intramural or extramural funding supported any aspect of this work.

Beniamino Brunetti, M.D.

Stefania Tenna, M.D., Ph.D.

Achille Aveta, M.D.

Francesco Segreto, M.D.

Paolo Persichetti, M.D., Ph.D.

Plastic and Reconstructive Surgery Unit

Campus Bio-Medico of Rome University

Rome, Italy

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1. Hofer SO, Posch NA, Smit X. The facial artery perforator flap for reconstruction of perioral defects. Plast Reconstr Surg.. 2005;115:996–1003 discussion 1004–1005
2. D’Arpa S, Cordova A, Pirrello R, Moschella F. Free style facial artery perforator flap for one stage reconstruction of the nasal ala. J Plast Reconstr Aesthet Surg.. 2009;62:36–42
3. Fabrizio T, Savani A, Sanna M, Biazzi M, Tunesi G. The retroangular flap for nasal reconstruction. Plast Reconstr Surg.. 1996;97:431–435
4. Seo YJ, Hwang C, Choi S, Oh SH. Midface reconstruction with various flaps based on the angular artery. J Oral Maxillofac Surg.. 2009;67:1226–1233
5. Fabrizio T, Tassinari J, Mori A, Orlandino G. The retroangular flap in facial reconstruction: The exhaustive point of view. Plast Reconstr Surg.. 2012;129:567e–568e
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