For the first stage of this procedure, an extended trapezius musculocutaneous island flap is developed based on the transverse cervical vessels. The accessory nerve innervation to the remaining trapezius muscle can be preserved. Once the flap is divided prior to insetting, it has, of course, a random-pattern circulation.

As with other methods of total nasal reconstruction, the initially reconstructed nose should be 20% to 30% larger than the desired final goal because of shrinkage. A cutaneous segment of flap 16 cm long by 10 cm wide is elevated onto the trapezius muscle carrier, which is 16 × 5 cm.

Initially, a triangular incision (the apex located over the acromion) is made lateral to medial along the clavicle and the anterior border of the trapezius muscle to allow identification of the transverse cervical vessels into the posteroinferior part of the neck. This incision provides access to the lower neck for identification of the posterior belly of the omohyoid muscle (crucial for convenient location of the transverse cervical vessels) and dissection of the trapezius muscle and eleventh nerve. It also allows external delivery of the vascular pedicle from the neck to increase the arc of the flap. In dissecting the transverse cervical vascular pedicle, overzealous exposure of the vessels should be avoided.

The distal cutaneous portion of the flap, dissected caudal to the scapular spine, is tubed onto itself. The end is attached to a cephalic-based half-circle flap developed over the glabella (Fig. 62.1). The length of the half-circle or trapdoor flap should equal the radius of the tubed portion of the flap. The muscle portion of the flap is not rolled onto itself because of bulkiness and the risk of compressing the vascular pedicle.