title: The Folded Ulnar Forearm Flap for Nasal Reconstruction.
abstract: BACKGROUND
  Many strategies exist to reconstruct composite nasal defects, but free flaps are necessary for extensive defects. The workhorse radial forearm flap is hair-bearing and donor-site cosmesis is unfavorable. The ulnar forearm flap is overlooked despite important aesthetic benefits. The authors describe their experience with the ulnar forearm flap, with a novel folding technique in staged nasal reconstruction.
  
  
  METHODS
  Between December of 2010 and April of 2015, 10 nasal reconstructions in five men and five women were performed. Average patient age was 47.6 years (range, 31 to 76 years). The ulnar forearm flap was designed as a narrow contiguous flap along the ulnar vascular axis. Inset began with the nasal floor; the flap was then tubularized twice to create nasal passages before it was folded on itself for coverage. Caudal edges were sewn together to create alae and a columella. Follow-up time, complications, number of operations, and reconstructive duration were documented.
  
  
  RESULTS
  Average follow-up was 25.2 months (range, 18 to 44 months). Patients had satisfactory aesthetic and functional outcomes after 6.4 operations (range, five to eight) over 11.1 months (range, 8 to 18 months). Partial necrosis of the alar lining in one case was salvaged with the covering flap. Two cases of chondritis were managed with conservative débridement and antibiotics. One case of severe chondritis necessitated removal and de novo reconstruction.
  
  
  CONCLUSIONS
  The ulnar forearm flap is safe and reliable in nasal reconstruction, with superior donor-site cosmesis. The tubular folding method creates a vascular envelope amenable to same-stage framework construction. With thoughtful planning and sufficient refinement, excellent aesthetic and functional results are achievable.
  
  
  METHODS
  Therapeutic, V.
authors.affiliation: Taipei, Taiwan; Khartoum, Sudan; and Hamburg, Germany From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University; the Department of Surgery, Faculty of Medicine, University of Khartoum; and the Department of Plastic and Reconstructive Surgery, Agaplesion Diakonie Klinikum.
authors.forename: Yen-Chang
authors.initials: YC
authors.lastname: Hsiao
authors.forename: Jung-Ju
authors.initials: JJ
authors.lastname: Huang
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Zelken
authors.forename: Chih-Wei
authors.initials: CW
authors.lastname: Wu
authors.forename: Chun-Shin
authors.initials: CS
authors.lastname: Chang
authors.forename: Mohamed
authors.initials: M
authors.lastname: Abdelrahman
authors.forename: Georgios
authors.initials: G
authors.lastname: Kolios
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D005542:Forearm / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D012225:Rhinoplasty / Q000379:methods*; D013524:Surgical Flaps; D014457:Ulna / Q000637:transplantation
references.citation: Menick FJ, Salibian A. Microvascular repair of heminasal, subtotal, and total nasal defects with a folded radial forearm flap and a full-thickness forehead flap. Plast Reconstr Surg. 2011;127:637–651
references.citation: Walton RL, Burget GC, Beahm EK. Microsurgical reconstruction of the nasal lining. Plast Reconstr Surg. 2005;115:1813–1829
references.citation: Menick FJ. A new modified method for nasal lining: The Menick technique for folded lining. J Surg Oncol. 2006;94:509–514
references.citation: Hsiao YC, Abdelrahman M, Chang CS, et al. Chimeric autologous costal cartilage graft to prevent warping. Plast Reconstr Surg. 2014;133:768e–775e
references.citation: Murrell GL, Burget GC. Aesthetically precise templates for nasal reconstruction using a new material. Plast Reconstr Surg. 2003;112:1855–1861
references.citation: Sieg P, Bierwolf S. Ulnar versus radial forearm flap in head and neck reconstruction: An experimental and clinical study. Head Neck. 2001;23:967–971
references.citation: Brown EN, Chaudhry A, Mithani SK, et al. Long-term vascular, motor, and sensory donor site outcomes after ulnar forearm flap harvest. J Reconstr Microsurg. 2014;30:115–120
references.citation: Rodriguez ED, Mithani SK, Bluebond-Langner R, Manson PN. Hand evaluation following ulnar forearm perforator flap harvest: A prospective study. Plast Reconstr Surg. 2007;120:1598–1601
references.citation: Tan ST, James DW, Moaveni Z. Donor site morbidity of free ulnar forearm flap. Head Neck. 2012;34:1434–1439
references.citation: Huang JJ, Wu CW, Lam WL, et al. Anatomical basis and clinical application of the ulnar forearm free flap for head and neck reconstruction. Laryngoscope. 2012;122:2670–2676
references.citation: Menick FJ. Discussion: Optimal use of microvascular free flaps, cartilage grafts, and a paramedian forehead flap for aesthetic reconstruction of the nose and adjacent facial units. Plast Reconstr Surg. 2007;120:1208–1216
references.citation: Wong CH, Lin JY, Wei FC. The bottom-up approach to the suprafascial harvest of the radial forearm flap. Am J Surg. 2008;196:e60–e64
references.citation: Mathy JA, Moaveni Z, Tan ST. Perforator anatomy of the ulnar forearm fasciocutaneous flap. J Plast Reconstr Aesthet Surg. 2012;65:1076–1082