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Page 8 of 14 Sciegienka et al. Plast Aesthet Res 2022;9:1 https://dx.doi.org/10.20517/2347-9264.2021.76

Cheek rotation flap (Mustardé flap)
The cheek rotational flap, or Mustardé flap, was described by Mustardé in 1971. It is useful when there is a
significant vertical defect of the anterior lamella of the lower eyelid that spans > 70% of its length. It has a
wide-based pedicle and excellent vascularity, which makes necrosis of the flap uncommon, and the flap
provides an excellent support for free grafts if necessary .
[23]
An incision is made from the lateral aspect of the defect to the lateral canthus and extends superolaterally,
then inferiorly ending at the preauricular area. The flap is elevated in the subcutaneous plane widely to
create a tension-free closure. The most medial aspect of the flap should be oriented vertically to reduce the
chances of a standing cone. Additionally, a deep inverted triangle may need to be excised inferior to the
defect to allow the flap to rotate adequately. The flap is tacked to the medial wall of the orbit medially and
the lateral wall of the orbit laterally. Some will place a small vacuum drain in the wound to prevent fluid
collection formation .
[24]

Some disadvantages of the Mustardé technique are the possibility of lower eyelid retraction with scar
contracture, ectropion, entropion, and epiphora, as well as risks of facial nerve damage, hematoma
formation, and excessive facial scarring.

Lateral orbital flap
The lateral orbital flap is a pedicled transposition flap that can be used to reconstruct the upper or lower
eyelid as well as periocular adnexa, including the eyebrow and orbit in cases of orbital exenteration. As with
other eyelid reconstruction techniques, both function and cosmesis is considered when designing the lateral
orbital flap. The flap is designed between the lateral canthus and the sideburn as a crescent-shaped island
and can be as large as 3 cm × 5 cm. The flap is supplied by the arterial arcade between the zygomatic orbital
artery and zygomatic facial artery with or without the inclusion of the named artery, depending on the
reconstructive requirements. The pedicle is designed on the medial edge of the flap. Thin flaps containing
only skin should be elevated when reconstructing the eyelids, while subcutaneous fat and possibly
orbicularis oculi should be elevated with the flap to repair thicker adnexal structures or fill the orbit. Care
must be taken when dissecting deep to the SMAS in this location to avoid damaging the frontal branch of
the facial nerve. The flap is finally rotated 180 degrees about its medially based pedicle, and the resulting
defect is closed primarily resulting in a rather inconspicuous scar. If eyebrow reconstruction is required, flap
elevation can extend into the sideburn to capture a small amount of hair-bearing skin; this portion is then
transposed into the portion of the missing brow.

Compared to other techniques, the lateral orbital flap is advantageous because it has good color and texture
match to the periorbital tissues, can include hair-bearing skin for brow reconstruction, has a rich blood
supply making necrosis rare, and the resulting scar is favorable. Disadvantages include the risk to the facial
nerve and size limitation of the flap [25,26] .

Nose
Soft tissue reconstruction of the nose presents challenges that are not found in other portions of the face
because of its unique topography and deep anatomy. Understanding the nasal subunits is crucial to
performing optimal reconstruction and includes the dorsum, paired nasal sidewalls, nasal tip, alar subunits,
and columella [Figure 5]. In general, partial subunit reconstruction yields inferior results compared to
replacing entire subunits or surgically redefining subunits. One must consider augmenting reconstructive
plans if the inner mucosal lining of the nose is affected, which should not be replaced with keratinized
skin .
[27]