PURPOSE:
The composite tissue allograft (CTA) holds promise for the future of facial reconstruction, allowing the selective replacement of specialized structures such as the eyelid, lips and nose. While initial reports have focused on transplantation of most or all of the face, clinical experience demonstrates a greater need for the replacement of individual facial units. We examined whether these unique functional components- the eyelids, lips, and nose- could be reliably harvested as individual units, and defined the anatomy of these composite flaps.
METHODS:
17 fresh cadaver heads were dissected, yielding 29 composite facial flaps: 24 eyelid flaps, 3 nasal flaps, 1 upper and lower lip flap, and 1 combined nasal/lip flap. The internal carotid (ICA), facial(FA), and superficial temporal arteries(STA) were isolated, cannulated and injected with a specific color of gelatin/dye mixture. In each flap, the adequacy of each arterial in-flow system was examined (Angular and Tranverse facial artery for the composite eyelid flap; Superior and Inferior Labial artery branches for the composite lip flap; and Angular and Lateral Nasal arteries for the nasal flap). In five of the cadaver heads the angular and superficial temporal arteries were cannulated and 3D CT angiography was performed.
RESULTS:
In the case of the composite eyelid flap, the acrylic dye injected into the STA uniformly stained the skin and subcutaneous tissue of the eyelid/periorbital facial unit, extending superiorly onto the lower brow. There was direct perfusion of the periorbital subunit via the Transverse Facial Artery (TFA) in 60% of the flaps. In the other 40% a TFA branch was either missing or was extremely small. In those cases the temporal artery sent of larger branches into the eyebrow and upper lid region and the cadaver had a dominant Angular artery. Injection into the Facial Artery resulted in staining of the skin and soft tissues in the medial canthal region and superior eyelid skin in approximately 70% of specimens. In the other 30% the angular artery was not present above the lateral nasal sidewall.
In the composite lip flap, injection of the facial artery led to uniform staining of the skin, mucosa, and subcutaneous tissues in 100% of the flaps via the superior and inferior labial artery.
For the nasal flaps, staining of the tissues was variably present after injection into the angular artery via the facial artery. The angular system either ended very proximally (at or proximal to the nasal ala), or was of extremely small caliber.
These findings were all corroborated by CT data.

CONCLUSION:
A composite eyelid flap can be reliably elevated utilizing either the TFA or the Angular artery based on our injection studies and CT angiography data. A composite upper and lower lip flap is reliable if based on the superior and inferior labial arteries.
Preliminary data on the composite nasal flap suggested that it cannot reliably be based on the angular arterial supply, as in some cadaver specimens the angular artery terminated very proximally (at or proximal to the nasal ala), or it was of extremely small caliber.