PART 1 — PRINCIPLES

5 Prefabrication and
Prelamination
Indranil Sinha | Lifei Guo | Julian J. Pribaz

of the head and neck region, where aesthetic, structural,

INTRODUCTION
Flap prefabrication and prelamination are distinct tech-
niques designed to address complex reconstructive needs.
While these techniques are generally not primary recon-
structive options, their usage has increased in response to
demands for more sophisticated reconstructive efforts. In
reconstructive surgery, a delicate balance exists between the
availability of matching donor tissue and the complexity of
the recipient defect. Prefabrication and prelamination tech-
niques have been applied to areas where a special surface,
contour, or structure is desired and reconstructive goals
cannot be met by conventional means. Areas of the body
where prefabrication (Fig. 5.1) and prelamination have
played a role in reconstruction include facial subunits, facial
cartilage, facial skeleton, oropharynx/esophagus, and the
penis (Tables 5.1–5.5).1–26 This chapter focuses on problems
and functional needs are complex and demanding, with
scarce reconstructive options.
They terms flap “prefabrication” and “prelamination” are
two distinctive entities in reconstructive surgery. Flap prefab-
rication, first introduced by Shen in 1982,27 describes a two-
stage process: the introduction of a vascular pedicle into a
body of tissue that bears desired characteristics of the area to
be reconstructed, followed by a transfer of this neovascular-
ized tissue into the defect based on its implanted vascular
pedicle. Flap prelamination, a term coined by Pribaz and Fine
in 1994,28 also refers to a two-stage process, whereby one or
more tissues are engrafted into a reliable vascular bed to
create a composite flap. This flap is subsequently transferred
on its original vascular supply, en bloc, for reconstruction. A
clear understanding of these two techniques is helpful in
choosing the appropriate method to deal with a specific clini-
cal problem and also for scientific communication.

Desired skin flap • Tissue expanded

fully at 8 weeks

Muscle TE • Neovascularization
of skin and capsule
around tissue
Deep vascular pedicle expander

Pedicle with fascia

or small cuff of
A muscle dissected out C Gore-Tex

Vascular pedicle • Prefabricated flap is

placed subcutaneously raised off of the tissue
TE on top of tissue expander expander. The capsule
layer is included with
Gore-Tex tubing around
the flap
proximal pedicle to TE
facilitate later
• Gore-Tex around
flap harvest
proximal pedicle
Expansion started at facilitates flap
1 week and continued dissection
B Gore-Tex for 8 weeks D Gore-Tex
Figure 5.1 Flap prefabrication technique.

16

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 CHAPTER 5 — Prefabrication and Prelamination 17

Table 5.1 Clinical applications of prefabrication and prelamination: Facial soft tissue subunits

Defect Technique Flap location Technique description References

Lips
(a) Superficial (hair- Direct axial Scalp/submental Staged transfer of hair-bearing flap from Hyakusoku et al.1
bearing) lip loss flap scalp scalp/submental Pribaz and Guo2
(b) Full-thickness upper Prefabrication Submental Vascular pedicle implant + secondary Pribaz and Fine3
lip loss Prelamination forearm transfer Costa et al.4
(c) Upper and lower lip Prelamination Tissue expander + skin graft on Baudet5
(mouth) loss underside of submental platysma flap
Subfascial skin grafts in radial forearm
flap
Cheek
(a) Partial thickness Direct axial Submental neck/ Submental island flap to cheek Martin et al.6
(e.g., burn) flap upper chest or Implant vascular pedicle beneath skin Faltaous et al.7
(b) Full thickness Prefabrication distant forearm and over a tissue expander with Kim8
Prelamination secondary transfer Khouri et al.9
Subfascial skin graft over a tissue Pribaz et al.10
expander in radial forearm territory, or Pribaz et al.3,11
subfascial mucosal graft and silicone Rath et al.12
sheeting in radial forearm territory Rath et al.13
(± nerve)
Neck
Burn contracture Prefabrication Thigh forearm Implantation of pedicle subcutaneously Khouri et al.9
upper chest placed over a tissue expander and Pribaz et al.10
subsequently transferred to neck

Table 5.2 Clinical applications of prefabrication and prelamination: Facial soft tissue with cartilage

Defect Technique Flap location Technique description References

Nose
(a) Partial or Existing Ear Ascending helical free flap based on Pribaz and Falco14
full-thickness laminated flap Forehead superficial temporal artery Gilles15
loss Prelamination Forearm Skin graft for lining and cartilage for support Pribaz et al.11
(b) Total Prelamination in paramedian forehead flap Costa et al.4
Skin graft for lining and cartilage for support Baudet5
in radial forearm flap
Ear
Absent ear Prelamination Forearm Carved costal cartilage graft or silicone Costa et al.4
framework covered with radial forearm Baudet5
fascia and skin graft with secondary Hirase et al.16
transfer to ear
Trachea/Larynx
(a) Tracheal defect/ Prelamination Radial forearm Mucosa or ear cartilage prelaminated onto Vranckx et al.17
stenosis Prefabrication Radial forearm antebrachial fascia for tracheal defects Delaere et al.18
(b) Hemilarynx fascia Free radial forearm fascial flap wrapped
defect around upper trachea, which is
subsequently moved for hemilarynx
reconstruction

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18 PART 1 — PRINCIPLES

Table 5.3 Clinical applications of prefabrication and prelamination: Facial skeleton

Defect Technique Flap location Technique description References

Maxilla
(a) Partial Existing Second toe Osteointegrated implants placed into proximal Pribaz and Guo2
– premaxilla laminated proximal phalanx with composite flap based on dorsalis Holle et al.19
(b) Extensive flap phalanx pedis artery and transferred to premaxilla Rohner et al.20
defect Prelamination Scapular or fibula Prelaminate scapular bone or fibula dermal graft +
wrap with silicone sheeting ± osteointegrated
implants
Mandible
Segmental or Prelamination Scapular Cancellous bone in carrier tray placed in scapular Orringer et al.21
total loss flap territory + secondary transfer to mandible

Table 5.4 Clinical applications of prefabrication and prelamination: Oropharynx and esophagus

Defect Technique Flap location Technique description References

Intraoral
Mucosa-lined Prelamination Forearm Mucosal grafts placed over radial forearm and later Rath et al.12
soft tissue loss transferred for intraoral reconstruction Carls et al.22
Chiarini et al.23
Esophagus
(a) Cervical Prelamination Radial forearm Skin surface of the radial forearm flap is rolled into a Chen et al.24
esophagus Prelamination Tensor fascia lumen during first stage to allow healing of suture
(b) Entire lata (TFL) line; during second stage 2 weeks later,
esophagus microvascular transfer is completed
Longer defect requires TFL flap with skin lumen
prelaminated the same way

Table 5.5 Clinical applications of prefabrication and prelamination: Penis

Defect Technique Flap location Technique description References

Penis
Absence secondary Prelamination Lateral arm radial Prelamination with skin tube for neo-urethra Young et al.25
to tumor or trauma forearm fibula reconstruction with subsequent transfer of Capelouto et al.26
osteocutaneous flap when using fibula

FLAP PREFABRICATION
CONCEPT
The first step in planning a reconstruction is to delineate
the specific needs. It is desirable to use flaps that provide
a good color match and restore surface and contour.
Regarding head and neck reconstruction, in particular,
the recipient site may require further specialized flaps,
such as hair-bearing or mucus-producing flaps, for optimal
reconstruction.29 Although there may be local flap options
with the desired characteristics, these may not have a reli-
able axial blood supply on which they can be transferred.
The technique of flap prefabrication provides this by
implanting an axial blood supply into the donor tissue,
rendering that tissue transferable once neovascularization
has occurred.
TECHNIQUE
A vascular pedicle includes at least an artery and its venae
comitantes, surrounded by an adventitial cuff. It may be
available locally or, if not, imported as a small free flap and
implanted beneath the intended donor tissue. The distal
end of the pedicle is ligated. To prevent scarring around the
base of the pedicle and to facilitate secondary harvest of the
prefabricated flap, a short segment of Gore-Tex (polytetra-
fluoroethylene) tubing or thin silicone sheeting can be
placed around the pedicle up to the undersurface of the
tissue that the new pedicle is expected to support (Fig. 5.1).
A nonadhesive sheeting may be placed under the implanted
pedicle, away from the proposed flap, not only to facilitate
secondary elevation of the flap but also to shunt the direc-
tion of neovascularization from the pedicle toward the flap
to be prefabricated. A tissue expander is frequently used
in this capacity. In experimental animal models, a neural

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island flap can also be prefabricated. In this model, a periph-
eral nerve can be placed under subcutaneous tissue and the
intrinsic vasculature of the nerve can supply the flap follow-
ing a delay period.30
FLAP MATURATION
Neovascularization between the implanted pedicle and the
donor tissue matures by 8 weeks in humans.3 However,
experimentally, maturation may possibly be hastened. Angio-
genic factors, such as basic fibroblast growth factor (bFGF)31
and vascular endothelial growth factor (VEGF),32 have been
shown in animal models not to improve flap survival by
increasing its vascularity.33 Flap delay has also been success-
fully employed, experimentally, to accelerate neovascular-
ization.34 By virtue of the need to prefabricate the donor
tissue (which lacks a good axial blood supply), the delay is
accomplished by progressively raising the flap tissue off
its non-axial blood supply, thus rendering it dependent
on the implanted pedicle. Although the contact area of
the vascular pedicle did not seem to be significant in our
initial experiments, others have found that there is a
proportional relationship of pedicle size and the rate of
neovascularization.35
Another helpful adjunct is the use of tissue expansion.36
Tissue expansion and flap prefabrication both are two-stage
procedures and thus complement each other nicely. The
implanted pedicle is placed directly underneath the donor
tissue and above the expander. Expansion can start as early
as 1 week and may be monitored by Doppler ultrasonogra-
phy. Expansion can be as aggressive, as allowed by the con-
tinued presence of the Doppler signal of a patent pedicle
and clinical observation of flap color. Tissue expansion
accomplishes four things: (1) it provides an abundance of
tissue that facilitates donor site closure following final trans-
fer; (2) it thins out the donor tissue flap, which is helpful
in head and neck reconstruction; (3) it provides mechanical
stretch that stimulates endothelial cells to proliferate,
thereby enhancing the rate of neovascularization; and (4)
it focuses the direction of the neovascularization from the
implanted pedicle toward just the side of the prefabricated
flap. Assessment of flap vascularity and viability by modali-
ties designed to evaluate perfusion may be useful in preop-
erative planning and optimizing flap harvest.37
FLAP TRANSFER
During the second stage of flap prefabrication, the prefab-
ricated flap is transferred to its final location, based on its
newly acquired axial blood supply. This can be done locally
as a pedicled flap if close to the defect or via microvascular
anastomosis if prefabrication is at a remote site (Fig. 5.2). A
commonly observed problem seen after flap transfer is tran-
sient venous congestion. This may be caused by unequal
neovascularization of the lower-pressured venous system
compared with the higher-pressured arterial system of the
same pedicle. This problem can be ameliorated in several
ways. All maneuvers that enhance neovascularization,
including flap delay, lengthening maturation time, or
increasing the contact area between the pedicle (usually in
the form of a fascial flap) and the donor tissue, would help.
Also, other strategies such as delayed insetting, temporary
leeching (chemical or medicinal), avoiding flap folding or,
if possible, performing an additional venous anastomosis
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CHAPTER 5 — Prefabrication and Prelamination 19
Implant regional AV pedicle Regional transfer of prefabrication flap
Implant vascular pedicle into proposed flap (8 weeks)
Micro Micro
Implant distant AV pedicle Distant transfer of prefabrication flap
Figure 5.2 Various algorithms in flap prefabrication.
using a native subcutaneous vein in the prefabricated flap
can all help to minimize flap venous congestion. Finally,
there was a recent report of a further surgical delay per-
formed at 6–7 weeks after pedicle implantation and 2 weeks
before flap transfer that was shown to minimize venous
congestion in that series.38
CLINICAL EXAMPLES
As illustrated in Figure 5.2, flap prefabrication can be
designed in any of the four basic forms. With proper plan-
ning, it is possible to avoid performing microvascular anas-
tomoses in two separate settings by choosing pedicles in
nearby sites to fabricate a new flap with desirable character-
istics. Choice of a design hinges on two questions: What is
needed? What is available? With the patient presented in
Figure 5.3, it is important to reconstruct the central defect
in her face with similarly matched skin. Local reconstructive
options were not available, as she previously underwent
right external carotid artery embolization for an arteriove-
nous malformation and suffered full-thickness skin necrosis.
In such cases, a flap may be prefabricated in the submental
area by utilizing the descending branch of the lateral cir-
cumflex femoral vessels with microvascular transfer. The
newly axialized submental flap may be transferred 8 weeks
following the original procedure as a pedicled flap.
The patient illustrated in Figure 5.4 requires a significant
contracture release and resurfacing of her neck after a dis-
figuring burn injury suffered many years before. There are
no local options for reconstruction, as the surrounding skin
has also undergone traumatic injury. For this type of defect,
distantly prefabricated skin flaps have been used previously.
In this patient, the deep inferior epigastric vessels were
utilized to prefabricate a sizable and robust abdominal skin
flap. Transfer of such distantly prefabricated flaps then takes
place via microvascular anastomosis (Fig. 5.4).
Sometimes, one encounters the need to reconstruct a
specialized surface, for instance, a hair-bearing area of the
face. While local options for a good surface match may exist,
it may not possess a reliable blood supply. Prefabrication can
be used to bring in this blood supply. The patient illustrated
in Figure 5.5 needs to have his cheek skin and lip mustache
reconstructed after a disfiguring burn suffered several years
prior to presentation. While he still has enough scalp hair
to serve as a donor, the extent of his burn injury with sub-
sequent scarring would prevent a reliable transfer, all the
way to the midline, of any hair-bearing surface. The tempo-
ral parietal fascia (TPF) is not available in this patient due
20 PART 1 — PRINCIPLES

A B C

D E
Figure 5.3 (A) Frontal view of a young patient with a history of a right facial arteriovenous malformation, presenting with facial contour defor-
mity following an embolization of her lesion and reconstruction subsequent facial tissue necrosis. Furthermore, there was thrombosis of multiple
external carotid branches. (A) The patient continued to have significant facial contour deformity and tethering of right oral commissure following
debridement and radial forearm free flap reconstruction. (B,C) Design of flap to be prefabricated in the submental region, with descending
branch of the lateral femoral circumflex vascular pedicle transferred into the area and anastomosed with the external carotid; Gore-Tex tubing
was applied to the proximal pedicle (visible in C). The transferred pedicle was placed over a tissue expander. (D) Early postoperative result
following prefabricated flap transfer. A left facial artery musculomucosal (FAMM) flap was utilized for upper lip reconstruction. (E) Result 6
months later, after two thinning and refinement procedures.

to the burn injury. For cheek and mustache reconstruction,
a distant radial forearm fascial flap along with its pedicle is
anastomosed into the external carotid and jugular systems
and inserted over a tissue expander beneath a hairy postau-
ricular region of the scalp. This newly axialized hair-bearing
flap is transposed 8 weeks later to reconstruct the patient’s
mustache and beard area.
Possibilities with flap prefabrication are endless and many
combinations of transplanted vascular pedicles, donor
tissues, and geographic locations have been described for
various clinical needs. This technique is especially powerful
in reconstructing specialized tissues, such as hair-bearing
areas and nerves (in cases of vascularized nerve grafts),39
where conventional approaches are often inadequate.
FLAP PRELAMINATION
CONCEPT
The word “lamination” means bonding together of thin
sheets. In reconstructive surgery, the term flap prelamination
describes a two-stage process. The first stage involves adding
different layers into an axial vascular territory, allowing time
for the tissues to mature before being transferred. During
stage 2 the laminated layers are transferred to the defect as
a composite structure based on the original axial blood
supply. As with any composite graft, these added layers have
to be sufficiently thin or small for them to take. The ratio-
nale for prelaminating those layers at a different site prior
to transfer rests on the belief that this offers the best chance
for the prelaminating layers to heal, stabilize, and assume
their expected structures and positions if the construction
is done in a reliable vascular bed at a less conspicuous
site versus in situ, where local complicating factors can
be numerous. This is particularly important for reconstruc-
tion of functional units that need to be transferred
to complex local environments, where loss of structural
integrity may precipitate grave complications, for example,
neo-urethra in the perineum and neo-esophagus in the
mediastinum.
TECHNIQUE
Aside from skin, the added graft materials may be as diverse
as cartilage, bone, mucus-producing membrane,40 nerve

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 CHAPTER 5 — Prefabrication and Prelamination 21

A B

C D

E F

Figure 5.4 (A) A young woman with extensive burn scars in the neck, neck resurfacing
and contracture release. (B,C) Given the lack of donor sites, as well as the need for relatively
large amounts of skin, a template was designed in the patient’s lower abdomen. Bilateral
deep inferior epigastric vessels were harvested and placed subcutaneously, overlying a
tissue expander. Gore-Tex tubing was again applied to the base of the pedicle. (D) Appear-
ance of prefabricated lower abdominal flaps following expansion. (E) A large, pliable cuta-
neous flap was harvested and maintained complete vascularity on a single pedicle. (F)
Following neck contracture release, there was a significant portion of the neck that required
G resurfacing. (G) The 6-month postoperative outcome following prefabricated flap inset.

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22 PART 1 — PRINCIPLES

C
A B

E F G

H I J
Figure 5.5 (A) A 59-year-old man with extensive burn scars in the forehead, right orbit, upper and lower lips, reconstructed with a split-
thickness skin graft at the time of injury, wanted to have facial resurfacing and reconstruction of the mustache and beard to match the opposite
side. (B) A template illustrated the area to be reconstructed, hatched area designating mustache and beard skin with required hair. (C) Scapular
flap design and orientation for reconstruction of the forehead and right orbit. (D) Radial forearm fascial flap for flap prefabrication for the lips
and cheek. (E) Scapular free flap inset for the forehead and orbit defect, vascularized radial forearm fascia flap tunneled beneath the scalp and
laid over a tissue expander. (F) At 8 weeks later, the prefabricated flap was ready for transfer and additional scar revision on the right cheek
planned. (G) Intraoperative dissection of the prefabricated flap raised based on its implanted pedicles. (H) Early postoperative and (I,J) 9 months
later, the prefabricated flap has good hair growth.
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graft,13 cultured keratinocyte sheet,41 or bioengineered
tissues.42 Tissue expansion again can play an important role
in many cases of flap prelamination, especially when a large
surface is desired, for example, during reconstruction of
mucosal intraoral linings.
FLAP MATURATION
Because the blood supply is not manipulated, the time
required for a prelaminated flap to mature is shorter than
for a prefabricated flap3 – usually 3–4 weeks.
FLAP TRANSFER
Since the layering of structures takes place in an established
vascular territory, venous congestion is usually not the
problem in a prelaminated flap that it can be in a prefabri-
cated flap. However, all flaps, including prelaminated flaps,
become edematous after transfer and exhibit increased scar-
ring at each healing interface. In attempting to reconstruct
complex 3-dimensional structures, the multiple layers with
scarring and contractile forces at each interface can result
in distortion and loss of contour of the flap. Because of this,
the initial result is often suboptimal and, in general, revision
operations are necessary.
CLINICAL EXAMPLES
The forearm remains a preferred site for non-bony flap
prelamination because of easy accessibility, patient conve-
nience, and the availability of a reliable but dispensable
vascular pedicle (usually radial or occasionally the ulnar
system, which has the benefit of being less hairy). Other sites
include the subscapular and fibular regions, where local
bony structures can be readily incorporated into the pre­
laminated flap for mandibular, maxillary, or even penile
reconstruction.
Distant prelamination, while it necessitates microvascular
transfer and generally lacks good color match, does have
the appeal of being inconspicuous and being able to utilize
local resource as needed (bone, cartilage, and other special-
ized tissues). Furthermore, there is more freedom in flap
reach with a flexible pedicle. While the decision to choose
a site for flap prelamination takes into account all these
factors, the foremost questions are always: What is needed?
What is available? Figure 5.6 shows a patient who needs a
total nasal reconstruction after an arteriovenous malforma-
tion resection. A flap is prelaminated in his forearm in the
ulnar artery distribution with a skin graft as for lining before
being transferred en bloc to the nasal and cheek defect. By
maintaining local options, further refinement of the nasal
reconstruction can be performed by utilizing cartilage grafts
for reconstruction of the defect and a forehead flap for
resurfacing.
In Figure 5.7, a patient presents with a large segment
of anterior maxilla missing. Reconstruction is planned with
a scapular free flap. The flap is prelaminated by the addi-
tion of a bone graft to mimic bony contour or the anterior
maxilla and a dermal graft. The construct is then covered
in a silicone membrane and allowed to heal. Approximately
4 weeks later, the flap is ready for transfer and inset. Once
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CHAPTER 5 — Prefabrication and Prelamination 23
the flap is healed, the patient may have dental implants
placed in the transferred bone.
If a flap is prelaminated within the head and neck
region, it takes only a pedicled transfer to inset the com-
posite flap. Local prelamination may involve the forehead
skin flap based on the supratrochlear or supraorbital
vessels, the TPF based on the superficial temporal vessels,
or the submental skin flap based on branches of the facial
artery. Advantages of prelaminating in the head and neck
include no need for microanastomosis during the second
stage of the procedure and a good match of skin color
and contour. A significant disadvantage is that the prepara-
tion stage may be socially awkward with obvious deformi-
ties present. However, if a suitable donor site is available
locally, it is clearly the best option. An example of local
tissue prelamination without the need for microanastomo-
sis is illustrated in Figure 5.8, where a forehead flap is
raised for nasal reconstruction, bilateral submental flaps
are prelaminated with full-thickness skin grafts for intra-
oral lining, and an Abbé flap is used to reconstruct the
upper lip.
Traditionally, prelaminated flaps are used to reconstruct
central facial defects11 and other anatomies that have a sig-
nificant degree of 3-dimensional structure, such as the penis
and esophagus. Extensive defects that are not amenable to
local flaps often require multiple layers reconstructed to
provide framework, lining, and tissue bulk for future refine-
ments. The goal of flap prelamination is not to provide a
one-step solution; it simply delivers the tissue support and
bulk to the area to render further reconstructive revisions
possible.
CONCLUSION
Flap prefabrication and prelamination offer sophisticated
approaches to difficult reconstructive needs that conven-
tional methods cannot meet. Tables 5.1–5.5 provide a com-
prehensive overview of the clinical applications of these two
techniques. The two techniques are distinctively different
and yet can be perfectly complementary. Prelamination can
add virtually anything to where there is a good axial blood
supply and prefabrication can bring an axial blood supply
to almost anywhere in the body. The two techniques can
even be combined when certain complex reconstructive
needs exist.
Prefabrication and prelamination can also serve as a
conduit through which products of tissue engineering and
embryonic stem cell technologies can be applied to the
reconstruction of head and neck defects. Tissues synthe-
sized in vitro with better structural, color, texture, and
functional match can be prelaminated to a site that
has already been prefabricated. Prefabrication of a bio­
absorbable matrix system can create a well-perfused scaffold
to which more and larger subunits can be pre­laminated. As
our understanding of the techniques evolves, the breadth
of their usage will also expand. Difficult problems that used
to baffle the very best reconstructive surgeons may no
longer seem so impossible and patients’ expectations may
also rise to a new level. This represents the beginning of a
new era in reconstructive surgery.
24 PART 1 — PRINCIPLES

A B

C D

E F
Figure 5.6 (A,B) A young woman with extensive defects of her nose, secondary following resection of an arteriovenous malformation. (C,D)
Reconstruction of the resultant defect was planned with a tailored radial forearm free flap that had been prelaminated with a skin graft of its
undersurface for mucosal lining. (E) Immediate postoperative outcome, as well as (F) postoperative outcome following cartilage grafting and
forehead flap for resurfacing.

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 CHAPTER 5 — Prefabrication and Prelamination 25

A B C

D E F

G H I
Figure 5.7 (A) A patient presented with a hypoplastic anterior maxilla and absence of anterior maxillary teeth. A scapular free flap was designed
for reconstruction (B). (C,D) A template was created and a bone graft fashioned and fixated to reconstruct the anterior maxillary contour. (E)
Next, a dermal graft was attached to the surface to provided soft tissue covering. (F) The prelaminated flap was covered in a silicone wrap,
whereas the pedicle was isolated by covering with a Gore-Tex graft. (G,H). Approximately 4 weeks later, the prelaminated flap was harvested
and transferred to the donor site. (I) Postoperative appearance approximately 4 months following the procedure. The prelaminated flap provides
a stable bony base for subsequent dental implant reconstruction.

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26 PART 1 — PRINCIPLES

A B C

D E F

G H I
Figure 5.8 (A) An 18-year-old man with extensive defects of the upper lip, cheek, and nose, secondary to noma infection. (B,C) Tissue
expander with full-thickness skin graft to be placed in the submental area deep to the platysma and anterior belly of the digastric muscle. (D)
Lateral view at 4 weeks showing expansion of the submental and forehead areas. (E) Intraoperative view showing the design of right and left
prelaminated, submental composite flaps, each based on the submental branch of the facial artery and also containing innervated platysma
muscle. (F) The tissue expander was removed and the left submental flap raised, showing healed skin graft on the inner aspect of the prelami-
nated flap. (G) Nasal reconstruction with local turndown flap for lining and cartilage grafts for support; forehead flap raised and ready to provide
external coverage of the nose; also, the two prelaminated submental flaps are in place and the Abbé flap is planned for reconstruction of the
central part of the upper lip. (H,I) Frontal and lateral views 6 weeks later.

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REFERENCES
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CHAPTER 5 — Prefabrication and Prelamination 27
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