Banner flap. The banner flap was proposed by Elliot (1969). The method is suitably used in the upper part of the nose, where the skin tissue is relatively loose.

The method is to design the single triangular flap or banner flap along the cutting line of the defect; the skin flap is designed horizontally, which will be conducive to the closure of the donor site. The scars can be hidden within the stripe lines, and both sides of the nose are kept relatively symmetrical. This skin flap can be used for repair of the defects with a diameter of less than 1.2 cm in any part of the nose (Fig. 10.3).

When the skin flap is harvested, its pedicle is equivalent to the diameter of the defect, and its length should exceed one third of the diameter of the defect. The adequate dissociation is performed on the layers such as under the muscle and perichondrium and above the periosteum, in order to facilitate rotation of the skin flap, and then the skin flap is inserted into the defect area; at the moment, the small triangle at the distal end is usually removed.

Bilobed skin flap. The bilobed skin flap is commonly used in the repair of the defects in the lower one third of the nose and is also used for repair of the defects in nasal dorsum or nasal side. This skin flap is only used to repair the defects with a diameter less than 1.5 cm, and it is needed to use the tissues in the two thirds of the nose.

Firstly proposed by Esser and Zimary, the method is to design a bilobed skin flap with a total rotation angle of 180°. But this design is flawed, and it will lead to a significant projection of “orecchiette” or appearance of a protuberance in the position of the pivot point; after its removal, the base and pedicle of the skin flap will be narrowed, and thus the blood supply of the skin flap will be affected.

In 1989, Zitelli proposed the optimal design method of the bilobed skin flap: the maximum rotation angle of each flap of the bilobed skin flap is 45–50°, and the total rotation angle is 90–100°. Along the margin of the defect, the Burow triangle included in the design is resected, then the first lobe of the skin flap is advanced downward, and the top point of the Burow triangle is taken as the pivot point of rotation of the bilobed skin flaps. The first lobe and the nearest defect have the same diameter; the second lobe is slightly narrower (it is generally 80% of the first lobe), but it must be ensured that the defect left after rotation can be closed directly, while the final incision should be made in the site with a minimum of tension to facilitate reducing the scar, generally in the lateral nasal wall. The skin flap is fully dissociated at the layers such as under the muscle, perichondrium, and periosteal surface, so as to ensure the blood supply of the skin flap. After the complete hemostasis of the wound is performed, the first lobe is rotated by 45–50° to cover the original wound, and then the second lobe is rotated by 45–50° to fill the defect left after rotation of the first lobe. The second donor site can be closed directly with absorbable suture lines (Fig. 10.4). Usually the rotating shaft should not be close to the margin of the nosewing and the lower eyelid to avoid distortions.

Rhomboid skin flap. The rhomboid skin flap comes from the neighboring buccal area, and it was originally used for repair of defects in nasal sides. The first side of the skin flap is designed along the nasolabial groove, the other side is located at the margin of the defect, and the last side crosses the cheek. The skin flap is lifted up, and the extensive dissociation is performed in the subcutaneous layer. It is easy to advance the skin flap to cover the defect through adequate dissociation, and it is not necessary to perform the “orecchiette” resection (Fig. 10.6). The postoperative scar is located in the nasolabial groove, or in the folds of the nosewing, or at the junction of the nasal side and the buccal area. Because the tension line is not in the vertical direction, therefore, the possibilities of occurrences of the lower eyelid eversion and the elevation of the lip or nosewing margin are minimal.

The buccal tissue can also be used as a simple advancement flap for nasal defect repair. Incise the skin to the subcutaneous layers at the nasolabial groove, the adequate dissociation is performed at 2.5 cm above the buccal area adjacent to the defect and the skin flap is advanced to cover the defect in the nasal side, and the donor site is closed directly. The buccal advancement flap can also be used in combination with other flaps for total nasal reconstruction, such as the median forehead flap.

The advancement flap of the nasal dorsum. The advancement flap of the nasal dorsum (Rieger method) is suitably used for repair of the defects in the nasal tip and the distal nasal dorsum with a diameter of less than 2 cm. Typically, the skin flap is used to repair the defect with a distance of at least 1 cm from the nosewing margin which can’t be lower than the nasal tip point. If the repair site is too distal, it will lead to postoperative nasal tip rotation or nosewing traction.

Rieger method: The incision line travels from the outside of the defect, extends along the junction of nasal side and buccal area upward to the area between the eyebrows, and stops near the contralateral inner canthus (downward to the inner canthal ligament); after skin flap harvesting, a random rotation skin flap with a long lateral pedicle is formed. The proximal end of the skin flap is lifted up at the subcutaneous level in the areas above bilateral internal canthi, then the separation is performed forward under the muscular layer to the distal end of the skin flap, and then the skin flap is advanced to the appropriate position and is sutured. The defect between the eyebrows after skin flap advancement is closed directly, and the complete dorsum nasal flap is formed into a V-Y advancement flap (Fig. 10.8).

Marchac and Toth improved the random advancement flap of Rieger into an axial pattern skin flap based on the angular artery branch issued near the inner canthus. Such design makes the pedicle become narrow, so that the mobility of the skin flap is greater.

After that, Ercocen designed the complete dorsum nasal island flap based on bilateral angular arteries, and the donor site between the eyebrows is closed with the V-Y method. Such skin flap is easy to be advanced to cover the defects in the nosewing margin, the distal nasal dorsum, nasal tip, and soft triangle and the range of 2–3 cm above the nasal columella.

Nasolabial flap. The nasolabial flap is the primary technology used in repair of the nosewing defects with a diameter of less than 2 cm. It can also be used to reconstruct the nasal columella and can be used as the donor site of the nasal lining tissues [4].

Auricular composite tissue flap. The non-pedicled auricular composite tissue flap transplantation is only suitable for repair of the nasal defects less than 1 cm². Due to blood supply limitation, with the increase in volume of composite tissue, the transplantation survival rate gradually decreases. The auricular composite tissues can be obtained from the crus of helix, auricular margin, cavum conchae, or earlobe. The crus of helix is the commonly used donor site, because it can provide three-tier structure of the skin, skeleton support, and lining, and remaining scars are not obvious. The transplantation of the auricular composite tissue with a diameter less than or equal to 1 cm is often used for repairs of the nosewing full-thickness defect and the nasal columella defect; the composite tissue including crus of helix and retroauricular skin can be jointly harvested for one-stage repair of the nosewing full-thickness defect and the lateral nasal wall defect involving only soft tissue. Due to lack of blood supply, the area of the transplanted tissue cannot exceed 1.0 cm × 1.5 cm, limiting the further application of donor site of the tissue. In 1993, Julian J. Pribaz firstly reported that the vascularized auricular composite tissue was used to repair the nosewing defect [12]; in the same year, Tanaka Y. reported that the auricular composite tissue flap pedicled with the retrograde superficial temporal blood vessel pedicle was used to repair the nasal full-thickness defect [13]. In 1999, Bakhach Joseph used the communication network between the frontal branches of the superficial temporal blood vessel and the supraorbital vessels as well as the supratrochlear vessels to design the pedicled transfer of retrograde auricular composite tissue flap to repair the nosewing defect [14]. In 2008, Qian Yunliang and Zhang Yixin from Shanghai Ninth People’s Hospital reported that the auricular composite tissue flap including auricular and preauricular tissues which was pedicled with the superficial temporal vessel was used to repair the full-thickness defect in tissues of multiple nasal subunits in 63 patients, expanded the clinical application of surgical techniques, and got a very good therapeutic effect [15]. These research and clinical application break through the limitation on the transplantation area of the traditional nonvascularized auricular tissue, so that it becomes a reality that the auricular composite tissue is taken as the best donor site [16–21].