Flap Design Research Articles

Advanced Deep-Plane Rhytidectomy: Advantages for Neck Treatment and Volumization of the Midface.

The aged neck is the most common motivator for patients seeking facial rejuvenation. Unlike the deflated midface, surgical treatment is still the gold standard for optimal outcomes. It is our view that the majority etiology of both the aged neck and deflated midface is gravity's effects on the superficial soft tissue envelope, leading to soft tissue redundancy. It is also our view that the deep-plane rhytidectomy is supported by anatomy, embryology, and clinical evidence as the best methodology to treat soft tissue redundancy without producing the aesthetic and longevity issues associated with superficial musculoaponeurotic system techniques. As one of the early pioneers in deep-plane rhytidectomy, the lead author will define contemporary advances in deep-plane technique such as dissection entry point, flap design, and flap fixation concepts that allow aggressive approach to treating both the aged neck and deflated midface.

A combined nasolabial and infra-nasal bi-lobe flap design with double transposition for reconstruction of the ipsilateral upper and lower lips associated with the commissure defect

A combined nasolabial and infra-nasal bi-lobe flap design with double transposition for reconstruction of the ipsilateral upper and lower lips associated with the commissure defect

The Vascular Anatomical Basis for a Well-Designed Reconstruction of the Ala Nasi by a Microsurgical Preauricular Flap Technique

Background: A microsurgical auricular flap represents a single-step technique for the reconstruction of full-thickness defects of the ala nasi. To achieve the best surgical outcomes, it is essential to have an exhaustive knowledge of the vascular network to improve the management of the surgical flap. This study aimed to provide an anatomical and surgical guide for a well-designed reconstruction of the ala nasi using a free preauricular flap. Methods: In this study, three fresh-frozen and two formalin-fixed human head specimens injected with red silicone rubber to enhance the arterial facial system were used. The reconstruction of the full-thickness defect of the ala nasi was performed using a microsurgical auricular flap technique, with the dimensions of the ala nasi and the preauricular flap duly noted. In addition, anatomical dissections were conducted, during which the positions and diameters of the main donor and recipient vessels were measured. Results: A presurgical evaluation was performed to define the flap design. A comparison of the shape and mean dimensions of the ala nasi defect (height 9.66 ± 1.40 mm; thickness 3.52 ± 0.53 mm) and the preauricular flap (height 8.50 ± 2.68 mm; thickness 3.92 ± 1.29 mm) indicated that this flap was an optimal option for the reconstruction of the ala nasi. The surgical procedure involved the full-thickness removal of the ala nasi, and the harvesting and insertion of the preauricular flap. The anatomical measurements demonstrated that the facial artery and veins were the optimal recipient vessels, with a diameter of >1 mm (2.08 ± 0.56 and 2.85 ± 0.74 mm), suitable for anastomosis with the superficial temporal artery and vein (1.86 ± 0.58 and 1.66 ± 0.15 mm). In addition, the postsurgical evaluations indicated a slight mean difference in the thickness (1.14 ± 0.65 mm) and height (1.68 ± 1.18 mm) between the ala nasi and helix and a satisfactory VAS score (7.9 ± 0.57). Conclusions: Our surgical and anatomical data provide compelling evidence in favour of free preauricular flap reconstructions of the ala nasi. This procedure allows for the correct choice of recipient vessels and the creation of a well-designed surgical flap.

Enhancing the coverage and rotation of anterior ethmoidal artery flap for septal perforation closure: Insights from a flap design study

Background and objectivesThe anterior ethmoidal artery flap (AEA) is a pedicle endonasal flap frequently used to repair septal perforations (SP). The posterior incision is the most complex to perform. The primary objective was to determine the minimum height of the posterior incision (PI) of an AEA completely cover an anterior septal perforation. Materials and methodsA cadaveric specimen was sectioned in the sagittal plane and a SP of 1 cm was created anteriorly. The PI of the AEA flap was made progressively at a height of 10, 20, 30, and 40 mm. The complete closure of the SP and the angle of rotation (AR) of the flap were assessed. ResultsAccording to the length of the PI the following results were obtained: PI = 10 mm: The SP was covered partially, and the AR was 45º. PI = 20 mm: The SP was fully covered, and the AR was 63º.PI = 30 mm and 40 mm: The SP was fully covered with redundant tissue.This study shows that an anterior ethmoidal artery flap that includes the nasal floor and the inferior meatus mucosa combined with a posterior incision of 20 mm could result in adequate coverage of all margins of an anterior SP up to area 1a of the septum.

Comparison of different flap designs in soft tissues periodontal healing after lower third molars extraction: a descriptive review

The purpose of this descriptive review was to assess post-operative periodontal outcomes of adjacent molar sites after the extraction of lower third molars, comparing different surgical techniques. The electronic search strategy was conducted on different databases (PubMed, Scopus, and Web of Science) fitting the following selection criteria: clinical human studies (RCTs, retrospective and prospective); studies comparing different flap designs (e.g., envelope, triangular, and trapezoidal flaps) for surgical extraction of lower 3rd molars; studies assessing clinical outcomes of periodontal healing at adjacent molar sites. Studies included had to present a minimum follow-up of 1 month and at least variations of probing pocket depth (PPD) at 2nd molar site between baseline and follow-up. The search strategy considered a total of 148 records: based on the predetermined eligibility criteria, 24 articles were read, and 9 were finally identified. Regarding the primary outcome considered (PPD at 2nd molar site), no significant differences in its reduction between baseline and follow-up were found comparing different flaps designs. However, the greatest clinical attachment loss (CAL) was generally reported using a trapezoidal flap. Considering the heterogeneity of studies included, after 1 to 6 months of follow-up, no substantial evidence can be assumed for or against the use of a particular flap design for the extraction of lower third molars.

A breast sharing technique using the pedicled IMAP flap for delayed breast reconstruction and contralateral symmetrising mammaplasty: A case series and evolution of the surgical technique in selected patients

IntroductionThe ‘breast-sharing’ procedure uses the disposable tissue as a flap to reconstruct the post-mastectomy defect. This enables simultaneous breast reconstruction and contralateral symmetrisation without additional donor site morbidity. However, controversies related to the oncological safety of this procedure have prevented its widespread uptake. We aim to present this technique based on a pedicled internal mammary artery perforator (IMAP) flap and discuss its technical feasibility and oncological safety. Patients and methodsBetween April 2013 and May 2022, a series of 10 consecutive patients underwent a breast-sharing procedure using the pedicled IMAP flap for breast reconstruction. Clinical and surgical aspects of the breast-sharing procedure were analysed. ResultsIn all cases, the breast-sharing technique allowed for simultaneous breast reconstruction and contralateral breast symmetrisation. Immediate complications included two total venous congestions and one hematoma. Three flaps had distal flap congestion. One flap required debridement and local flap reconstruction. All flaps required fat grafting during the secondary procedures to improve breast symmetry. With an average follow-up of 5,6 years, there was no evidence of recurrent disease. All patients were satisfied to very satisfied with the aesthetic outcome of this reconstructive option. ConclusionsThe breast-sharing technique based on the IMAP flap combines breast reconstruction and contralateral symmetrisation with good aesthetic outcomes in selected patients. The flap has a high complication rate related to venous drainage. Flap design modification and using ICG imaging may reduce venous congestion. A secondary venous micro-anastomosis at the axilla is highly recommended for persistent flap congestion. The reported incidence of contralateral breast cancer is low and thus the residual tissue obtained from the contralateral breast mammaplasty can be safely used for breast reconstruction. Level of EvidenceLevel IV

Free fillet flap: Outcomes in emergency microsurgical reconstruction of upper and lower limb

INTRODUCTIONDespite its infrequency, “spare-part surgery” represents a reconstructive strategy that uses segments of amputated limbs as donor tissue to preserve function in other injured anatomical regions. The purpose was to review our 14-year experience in emergency microsurgical reconstruction of traumatised limbs using free fillet flaps obtained from non-salvageable amputated parts. MATERIALS AND METHODSA retrospective observational study was conducted on patients who underwent urgent free fillet flap transfer for upper or lower limb reconstruction between 2007 and 2021. The characteristics and levels of injury, as well as the flap designs, functional outcomes and complications were documented. RESULTSA series of eight clinical cases is presented. One osteo-tendino-cutaneous and seven fasciocutaneous flaps were filleted from non-replantable amputated limbs for free transfer. Stable coverage of the dorsal aspect of the hand and fingers was achieved in three patients, and limb shortening was avoided in five patients. An open fracture of the thumb with bone defect, three below-knee stumps and one trans-metatarsal level were preserved. The mean Q-DASH score for upper limb reconstructions was 16.75 points. In all cases of lower limb reconstruction, the nerves were repaired, resulting in a protective sensitivity (S3 level) with no pressure ulcer development during the follow-up period. All patients were able to return to normal prosthetic ambulation with a mean Amputee Mobility Predictor Pro score of 45 points. Two haematomas, one surgical wound dehiscence, and two immediate revisions of venous anastomoses were registered. CONCLUSIONSThe microvascular filleted flap demonstrated versatility in the emergency reconstruction of complex limb injuries, providing stable coverage and optimised limb length preservation within a single major surgical procedure while eliminating morbidity from any other uninjured donor site.

Exploratory study on a novel minimally invasive tunnel like flap approach for orthodontic movement of dental implants.

To propose a new flap design that utilize a minimally invasive approach to move implants. We also propose a 3D method to track changes in implant position without the need for CBCT. Implants were inserted in two mongrel dogs then a minimally invasive tunnel like flap was made. Bone cutting around implants was done using piezotome device and orthodontic force was applied on the implants. For tracking positional changes of implants, an impression was taken then scanned with an identical implant copy inside. The pre- and post-treatment 3D images were then superimposed over each other to detect changes in implant position. Healing of the flap was rapid with minimal swelling and edema. The position of the interdental papilla was preserved maintaining optimal esthetic outcome. Implant pocket depth was maintained. Our 3D imaging method was able to accurately detect the movement that occurred in the dental implants after their movement with significantly higher resolution than CBCT (6μm for this method versus 76-300μm for the CBCT). This flap can preserve the esthetic soft tissue contour of implants during orthodontic movement allowing rapid healing with minimum swelling and edema. Moreover, our proposed 3D method has many advantages over CBCT in tracking the movement of implants by being non harmful and cheap thus allowing several follow up points. Orthodontic movement of implants can be required in cases of improperly placed implants or to intentionally place the implant in a certain position then altering it to avoid the need for bone grafting.

The Imageology Study and Clinical Application of Perforating Branch of Posterior Tibial Artery.

It is necessary to precisely locate the branches for better result of flap transplantation for the high variability of perforating branches of posterior tibial artery (PTA). In the research, digital subtraction angiography (DSA) and high-frequency ultrasound are jointly used to study the distribution and exact location of PTA perforating branches to guide clinical practice. From January 2020 to December 2022, 16 patients underwent DSA examination and 5 of them accepted further high-frequency ultrasound examination. The authors analyzed the distribution, number, location, direction, and lengths of PTA branches and used PTA perforator flaps to repair middle and inferior lower leg defects according to the above imaging findings. The donor site was repaired with skin grafts or a sequential PTA perforator flap. A total of 81 branches of PTA were identified in 16 patients. Most of the perforating branches were in the middle and distal thirds of tibia. There was a significant correlation between the length of perforating branches and their perforating sites. Cluster analysis showed that larger branches appeared most frequently in the range of 15 to 20cm from the tip of the inner ankle. 5 cases of PTA perforator flaps survived well. DSA can clearly show the distribution of PTA and its branches, especially the dominant ones. The imaging findings can effectively guide PTA perforator flap design and harvesting, and thus improve the result of flap transplantation.

An Optimal Scalp Rotation Flap Design: Mathematical and Bio-Mechanical Analysis

The design and implementation of successful rotational flaps of the scalp remains a complex process. There are several described techniques, all of which are based on a two-dimension surface, absent consideration of the convexity and thereby three-dimensional nature of the scalp. This has contributed to flaps that are either too small or unnecessarily large in a bid to compensate.Mathematical analysis using trigonometric and algebraic formulae were used to derive the relationship between the defect, triangulation, the contour of the scalp, the radius of the arc of rotation for the flap and scalp skin tension. Polyurethane models were used to test the applicability of the resultant formula, and a consecutive clinical case series is presented.Rotation flap dimensions were calculated using an apex angle of 30 degrees depicted as a two-dimensional construct. The contour of the defect was then measured as the depth of depression with radius of the rotation flap calculated based on the changes in flap surface area across the defect. Finite Element Analysis was utilised to measure redistribution of tension along the flap reconstructing the defect, and the efficacy of the approach confirmed in the consecutive clinical series. The current study provides a reliable flap design based on mathematical analysis, with evidence-based application to the clinical setting.

Salvage Operation of Head and Neck Reconstruction Using a Pedicled Latissimus Dorsi Myocutaneous Flap with Distally Positioned Skin Paddle

Background: There are many situations in head and neck reconstruction where a pedicled flap must be chosen over free flaps. In such situations, one of our options is a pedicled latissimus dorsi (LD) myocutaneous flap with distally positioned skin paddle with a more distal skin flap design. Methods: We performed 22 reconstruction cases using a distally positioned pedicled LD myocutaneous flap. When designing the skin paddle more distally than usual, it is important to include the lateral cutaneous branch of the 10th posterior intercostal artery. By splitting the skin paddle sections, the LD flap is flexible for use in complex head and neck defects. It can also be used for mandibular reconstruction by harvesting the flap with costal bone. Results: In all cases, the skin flaps survived, with a salvage rate of 100%. Conclusions: Because elevation of this flap is relatively easy, safe, and quick, this flap selection is considered practical in salvage cases after flap necrosis, and in cases after multiple procedures.

Prosthetic driven minimum invasive semilunar flap design for LSA

Prosthetic driven minimum invasive semilunar flap design for LSA

Development of operable modular louvers Sited in a single-sided ventilated room through 3D parametric optimization

The current design practices of buildings to respond to environmental inputs have led to operable envelopes with external louver blinds systems. The key aspect of any openable louver flap design is to optimize inlets that might induce ventilation for occupants with low indoor airflow. Computational Fluid Dynamics (CFD) in 3D parametric modeling investigated the influence of openable louver inlet geometries (right trapezoid) and positions in a ventilated room. A single-sided ventilated room designed with two mirrored split blocks of inlets attached to that wall perpendicular to the wind was employed for this study. Twenty-eight different inlet shape geometries with their cross-sectional changes were investigated. In addition, the inlets' rotation, orientation, and elevation differences were also studied. Wind tunnel experiments were conducted to measure airflows inside the model room to validate the CFD simulations. A discernible impact was observed when the inclined side of the right trapezoid was oriented upward or downward, where inlet flaps open to the sides of the window. The mean air velocity in the ventilated room becomes more than double when inlet flaps open to the sides of the window, where the elevation difference in the inlet blocks introduces the pressure difference compared to no elevation difference in inlets. This study guides into refining an operable modular louver design to enhance air circulation and natural ventilation in dwelling spaces.

Efficacy and Functional Outcomes of Platysma Myocutaneous Flap in Oral and Maxillofacial Reconstruction.

Maxillofacial reconstruction strives to restore the form and function of the maxillofacial region in patientswith deformities caused by trauma, disease, cancer, or congenital malformations. An array of surgical procedures has been advised for restoring soft tissues in the oral cavity, with varied degrees of efficacy. This prospective study seeks to provide a thorough understanding of the success rate, complications, functional outcomes, and patient satisfaction associated with the utilization of platysma myocutaneous flap (PMF) in this specialized domain. This study aims to elaborate on the PMF surgical technique, along with the flap design, outcomes, and intricacies associated with age, gender, the recipient site, and defect size. The study included 30 patients with oral malignancies who intervened under general anesthesia with wide local excision and reconstruction with PMF at a single tertiary care center. The results showed that the PMF is an efficient flap in the context of its ease of harvest, minimal donor site morbidity, low complication rates (infection - 26.67%, flap dehiscence - 16.67%, and flap necrosis - 6.77%), and ability to rehabilitate both form and function. In conclusion, the PMF stands as a viable alternative in oral and maxillofacial reconstruction, offering a combination of versatility, reliable blood supply, and potential for functional restoration.

Changes in soft tissue dimensions following horizontal guided bone regeneration with a split-thickness flap design – evaluation of 8 cases with a digital method

BackgroundPeri-implant soft tissue corrections are often indicated following alveolar ridge augmentation, due to the distortion of the keratinized mucosa at the area of augmentation. The objective of the current study was to evaluate the dimensional soft tissue changes following horizontal guided bone regeneration (GBR) utilizing 3D digital data.Methods8 mandibular surgical sites with horizontal alveolar ridge deficiencies were treated utilizing a resorbable collagen membrane and a split-thickness flap design. Baseline and 6-month follow-up cone-beam computed tomography (CBCT) scans were reconstructed as 3D virtual models and were superimposed with the corresponding intraoral scan. Linear changes of supracrestal vertical- horizontal soft tissue alterations were measured in relation to the alveolar crest at the mesial- middle- and distal aspect of the surgical area. Soft tissue dimensions were measured at baseline and at 6-month follow-up.ResultsPreoperative supracrestal soft tissue height measured midcrestally averaged at 2.37 mm ± 0.68 mm, 2.37 mm ± 0.71 mm and 2.64 mm ± 0.87 mm at the mesial-, middle- and distal planes. Whereas postoperative supracrestal soft tissue height was measured at 2.62 mm ± 0.72 mm, 2.67 mm ± 0.67 mm and 3.69 mm ± 1.02 mm at the mesial, middle and distal planes, respectively. Supracrestal soft tissue width changed from 2.14 mm ± 0.72 mm to 2.47 mm ± 0.46 mm at the mesial, from 1.72 mm ± 0.44 mm to 2.07 mm ± 0.67 mm and from 2.15 mm ± 0.36 mm to 2.36 mm ± 0.59 mm at the mesial, middle and distal planes, respectively. Additionally the buccal horizontal displacement of supracrestal soft tissues could be observed.ConclusionsThe current study did not report significant supracrestal soft tissue reduction following horizontal GBR with a split-thickness flap. Even though there was a slight increase in both vertical and horizontal dimensions, differences are clinically negligible.Trail registrationThe trail was approved by the U.S. National Library of Medicine (www.clinicaltrials.gov); trial registration number: NCT05538715; registration date: 09/09/2022.

Enhancing early-stage healing responses through the modified "Poncho" technique in customized titanium mesh-mediated bone regeneration: A soft tissue management approach-case series.

Soft tissue management is critical in bone augmentation surgery to prevent wound dehiscence. Several strategies for passive tissue primary closure have been explored. This article introduces a flap design known as the modified "Poncho" technique (MPT), integrated with customized titanium mesh-mediated bone regeneration, and investigates the healing quality during the initial stages of an incision. The cohort consisted of 5 patients undergoing customized bone regeneration procedures, concerned primarily with the successful integration and healing of the augmented bone site without complications such as wound dehiscence or infection. All patients were diagnosed with insufficient bone volume requiring augmentation to support future dental implants, necessitating the use of customized titanium mesh for guided bone regeneration. The MPT was detailed and applied during the customized bone regeneration procedures. Postoperative evaluations included recording complications and using Landry's healing index at intervals of 3, 7, 14, and 30 days post-surgery to assess the technique's performance in early wound closure. The study found that 95.7% of surgery sites experienced uneventful soft tissue healing within the observation period. Only 1 of 23 sites exhibited partial wound dehiscence at postsurgical days 14 and 30, accompanied by mild inflammation. The Landry's healing index increased from 3 ± 0.47 to a final value of 4.69 ± 1.06, indicating substantial improvement in healing over time. The MPT shows promise as an innovative approach for promoting passive and predictable primary wound closure beneath a digitally customized titanium mesh for bone regeneration, demonstrating a high rate of successful healing and minimal complications during the early postoperative phase.

Coverage of Soft-Tissue Defects of the Palm of the Hand: Introduction of a New Flap Design.

The palm is of great importance for maintaining a functioning hand. The reconstructive demands of thickness, texture, color matching, pliability, and sensation for palmar defects represent a unique challenge for plastic surgeons. This study introduced a novel versatile design for the ulnar palmar artery perforator flap (UPAPF) to cover large palmar soft-tissue defects of the hand. The fifth metacarpophalangeal joint was identified as a landmark where the perforator was nearly 1 to 1.5 cm proximal. A template of the defect was outlined after adequate debridement. Meticulous dissection was executed under loupe magnification to trace the perforator until an adequate length of the pedicle was obtained for rotation. The harvested type B fasciocutaneous flap was rotated nearly 90° to be insetting on the palmar defect. Two patients were presented with a soft-tissue defect of the palm measuring 4.8 × 5.5 cm2 and 3.8 × 5 cm2, respectively. The flap was harvested and positioned at the defects. The flaps survived in the 2 cases with minimal donor site complications. The patients acquired protective sensations within the flap at the end of the follow-up period. The UPAPF provides a stable coverage for palmar soft-tissue defects with satisfactory aesthetic and functional results. It is a convenient addition to the armamentarium for reconstructing palmar soft-tissue defects of the hand.

U-T Flap for Distal Symes Toe Amputation. A New Flap Adapted to Diabetic Ulcers of the Pulp of the Lesser Toes

The surgical management of diabetic ulcers of the tip of the toes complicated with osteomyelitis of the distal phalanx usually consists of the excision of the bone and soft tissue using a distal Symes toe amputation. This surgery is usually conducted through 2 coronal flaps. When the ulcer is away from the nail or extends further on the plantar side of the pulp, wound closure could be difficult to achieve resulting in wound dehiscence. In addition, the remaining toe is often too short when compared with the neighboring digits. The objective of this surgical technique is to propose a new flap design that could be simple and easy to learn, mainly when dealing with small-to-moderate–sized wounds. The U-T flap is designed to reduce wound complications and yield better esthetics. We found the U-T flap to be a reproducible technique with better outcomes in terms of surgical wound healing and final toe length, after excision of distal infected toes. Level of Evidence: Diagnostic level 5—expert opinion. See Instructions for Authors for a complete description of levels of evidence.

From Angiosomal to Bi-Angiosomal and Extra-Angiosomal Pedicled Perforator Flaps: Optimizing the Use of Local Tissues in Abdominal Wall Reconstruction.

The use of free-style and propeller perforator-based flaps has been popularized for the reconstruction of moderate size defects in the trunk and extremities, while their application in the field of abdominal reconstruction is seldom reported. The purpose of this report is to describe the authors experience with the use of pedicled perforator-based flaps in abdominal wall reconstruction, presenting the innovative concept of transition from angiosomal to bi-angiosomal and extra-angiosomal perforator flaps and showing applications of the different flap designs according to the multiple clinical scenarios. A total of 15 patients underwent abdominal wall reconstruction with angiosomal, bi-angiosomal, and extra-angiosomal pedicled perforator-based flaps harvested from the surrounding abdominal subunits for superficial or full thickness defects of the abdominal wall of moderate and large dimensions. The defects were consequent to soft-tissue sarcomas (STS) and non-melanoma skin cancer (NMSC) resection in 11 and 4 cases, respectively. Operative data, post-operative course, and complications were recorded. Moreover, at 12 months follow-up, patients were asked to rate the esthetic and functional outcomes of the reconstructive procedure on a 5-point Likert scale. Ten angiosomal perforator flaps (4 DIEP, 4 SCIP, 1 SEAP, and 1 LICAP flaps) and 5 bi-angiosomal and extra-angiosomal conjoined perforator flaps including different vascular territories (3 bilateral DIEP, 1 bilateral SEAP, and 1 ipsilateral DIEP-SEAP flap) were successfully transferred in 15 patients. In two patients, microsurgical anastomoses were performed to guarantee proper vascularization of the additional cutaneous territory. Mean age was 59.3 years. Defect sizes ranged from 98 to 408 cm2 (mean size was 194.7 cm2). Mean operative time was 280 min. Flap surface ranged from 108 to 336 cm2 (mean surface was 209.3 cm2). No major complications were registered. One bi-angiosomal bilateral DIEP flap suffered from partial necrosis and required an additional flap reconstruction. All patients underwent a 12-month follow-up except one, who did not show for clinical follow-up but responded at the Likert scale at clinical follow-up at 9 months. Overall patients' satisfaction was high, with mean esthetic and functional ratings of 4.27 and 3.87. The use of local tissues is an under-utilized solution in the field of abdominal wall reconstruction. Angiosomal, bi-angiosomal, and extra-angiosomal perforator flaps proved to be a reliable option to provide the transfer of a significant amount of tissue and offer like with like reconstruction while maximizing flap survival.

Enhancing the coverage and rotation of anterior ethmoidal artery flap for septal perforation closure: Insights from a flap design study

Background and objectivesThe anterior ethmoidal artery flap (AEA) is a pedicle endonasal flap frequently used to repair septal perforations (SP). The posterior incision is the most complex to perform. The primary objective was to determine the minimum height of the posterior incision (PI) of an AEA completely cover an anterior septal perforation. Materials and methodsA cadaveric specimen was sectioned in the sagittal plane and a SP of 1 cm was created anteriorly. The PI of the AEA flap was made progressively at a height of 10, 20, 30, and 40 mm. The complete closure of the SP and the angle of rotation (AR) of the flap were assessed. ResultsAccording to the length of the PI the following results were obtained: PI = 10 mm: The SP was covered partially, and the AR was 45º. PI = 20 mm: The SP was fully covered, and the AR was 63º.PI = 30 mm and 40 mm: The SP was fully covered with redundant tissue.This study shows that an anterior ethmoidal artery flap that includes the nasal floor and the inferior meatus mucosa combined with a posterior incision of 20 mm could result in adequate coverage of all margins of an anterior SP up to area 1a of the septum.