twentieth century, the paramedian forehead ap became the workhorse of nasal reconstructions, and the importance of reconstructing the nasal lining and structural framework also became apparent [14–17].

The melolabial ap has been extensively described in the literature for nasal reconstruction dating back to the late nineteenth and early twentieth centuries [18–23]. The melolabial ap can be utilized as an advancement, rotation, transposi­tion, and interpolated ap for the reconstruction of cutaneous defects [24, 25]. The melolabial ap can be tunneled into the oral cavity or nasal cavity [21]. The melo­labial ap is an important ap to consider in lip reconstruction, particularly recon­struction of the lateral lip [18, 26, 27]. The superiorly based melolabial interpolated ap was described by Baker etal. in 1995 with the primary objective of preserving the alar-facial sulcus [28]. While transposition, rotation, and advancement melola­bial aps are best suited for lip and cheek reconstruction, the interpolated melola­bial ap is best suited for reconstruction of the lower third of the nose.

Understanding the anatomy of facial regional aps hinges on an understanding of the relationships of surface landmarks to terminal branches of the external and inter­nal carotid artery branches and knowing the course of these vessels as they transi­tion from the sub-supercial musculoaponeurotic system plane to the subcutaneous plane. In this section, the anatomy of the supratrochlear, facial, supercial temporal, and deep temporal arteries will be discussed.

off the inferior and superior labial arteries and becomes more supercial distally. The facial artery is typically found in close proximity to the nasolabial fold and transitions from the sub-supercial musculoaponeurotic system plane below the oral commissure to very supercial in the subcutaneous plane at the level of the nasal base [37]. At its most distal aspect, the facial artery becomes more supercial, and the branches lateral to the melolabial fold allow for the versatility of the melo­labial ap. The venous drainage is via the facial angular vein.

The soft tissue layers of the temporal fossa are the skin, subcutaneous tissue, temporoparietal fascia, loose areolar plane, temporalis muscle fascia, temporalis muscle, and pericranium. The skin, subcutaneous tissue, temporoparietal fascia, and temporalis muscle fascia are all vascularized by the supercial temporal artery [5,

pedicle division much longer than the typical 2 to 3weeks. In these cases, it has been suggested to divide the lining pedicle at 2months and then divide the external ap pedicle and complete inset an additional 2 months following this [41]. Regardless of the technique utilized to address full thickness nasal defects, the num­ber of procedures is typically more numerous, and the time until completed result is typically longer. However, the chimeric paramedian-pericranial forehead ap allows for reconstruction of the nasal lining and external skin using a single ap [42]. The pericranium is utilized to reconstruct the nasal lining defect, and the forehead skin is utilized to reconstruct the cutaneous defect, which allows for signicant structural grafting during the rst stage of reconstruction [42]. Pedicle division and inset of this chimeric ap were completed at 1month given the patient’s history of nicotine use. There are multiple other techniques that have been described allowing for reconstruction of full thickness nasal defects with prelaminated forehead aps [43–45]. During a preliminary stage of reconstruction, the subcutaneous tissue plane can be dissected and a silicone sheet can be placed in this plane, therefore separating the galea from the cutaneous layer, and a split thickness skin graft can be applied to the deep surface of the galea which will serve as the nasal lining recon­struction [43].

The melolabial ap is an excellent option for nasal alar defects given the similar­ity in skin thickness and quality; however, it is less well suited for defects in the middle third of the nose given that the skin thickness tends to decrease in this area [24, 28]. The melolabial ap is also well suited for a variety of cheek and upper lip defects [18, 26, 27, 46, 47]. When utilized for nasal reconstruction, the melolabial ap is most commonly interpolated; however, in cases of upper lip and cheek recon­struction, the ap can be rotated, advanced, transposed, or interpolated depending on size and location of the defect. Although there is a rare application of this ap, the melolabial ap can be tunneled into the oral cavity or nasal cavity [21].

The temporoparietal and temporalis aps have been applied to a variety of defects. The temporoparietal fascia ap is a thin, pliable, and well-vascularized ap that has a variety of uses in the head and neck [5]. It can be transferred as a fascial, fasciocutaneous, and osseofasciocutaneous ap. The temporoparietal ap can be transferred as a fasciocutaneous ap in order to reconstruct the upper lip in men with hair-bearing tissue [1]. When transferred as a fascial ap, it has been used in reconstructing lateral skull base, anterior skull base, auricular, orbitomaxillary, facial, and oral cavity defects among others [1, 2, 5, 38, 48]. Although uncommonly utilized in the twenty-rst century, both the temporal muscle ap and the temporo­parietal fascial ap have been transferred with attached split calvaria bone grafts [49, 50]. Both the paramedian forehead ap and the temporoparietal ap are useful in complex eyelid reconstructions [48, 51–53]. The temporoparietal fascial ap has been extensively described for auricular reconstruction [3, 4]. The temporalis mus­cle can be utilized in orbitomaxillary defects, anterior and lateral skull base defects, facial defects, and oral cavity defects [29, 30, 54–56]. The temporalis muscle has some bulk to it allowing for partial obliteration of orbital and temporal cavities with vascularized tissue and can act as a well-vascularized tissue bed to be skin grafted.

The primary disadvantage of the temporalis muscle ap is the temporal hollowing that is seen postoperatively.

• Bipolar electrocautery

• Monopolar electrocautery

• Skin hooks

• Fine tip dissecting scissors

• Doppler probe