Anterior ethmoidal artery flap (AEA, Dragonfly)

The flap keeps its artery and pivots down from the upper septum onto the perforation.

First described by : Castelnuovo, Ferreli, Khodaei and Palma, Arch Facial Plast Surg 2011: 11 patients, median follow-up 51 months, no reopening. Extended and bilateral versions come from Barcelona (Alobid, Santamaría-Gadea) and Moscow (Rusetsky).

Unlike advancement flaps, which pull on the edges, this flap stays plugged into its artery: the septal branch of the anterior ethmoidal artery. A flap of mucosa is designed high on the septum, elevated with its pedicle, then rotated downwards to cover the perforation. Because it is vascularised, it tolerates tension-free coverage, exactly what large perforations lack. In exchange, it consumes septal mucosa and leaves its donor area bare.

1. 1Endoscopy and identification of the pedicle: the septal branch of the anterior ethmoidal artery runs from the roof down onto the septum.
2. 2Flap design according to the perforation: a 20 mm posterior incision is enough to cover a 1 cm anterior perforation completely, with about 63° of rotation (Garaycochea 2024).
3. 3Subperiosteal elevation of the flap, preserving the pedicle along its whole length.
4. 4Rotation and inset onto the perforation, sutured without tension; the other face is closed by advancement or with a second flap if the hole is wide.
5. 5Donor area left to heal by secondary intention, splints and rinses.

Named variants

• Anterior perforations, the ones that whistle, bleed and crust the most.
• Patients with cartilage or bone left around the hole: it is needed to raise the flap.
• First closure attempt, with intact high septal mucosa.
• Patients who prefer a purely endoscopic route, with no external incision or distant harvest.
• Large anterior perforations, in the extended or bilateral version, in an experienced centre.

• A septum already widely denuded, or several previous elevations: the flap can no longer be raised.
• Subtotal perforations where all remaining mucosa must be kept for another technique.
• Low and posterior perforations: the flap comes from above and does not reach easily.
• Cases where septal mucosa should be preserved for a possible revision: this flap consumes it.
• Unilateral alone for a perforation over 2 cm: prefer bilateral coverage.

Published results

• Partial flap necrosis if the pedicle is injured during elevation.
• Bare donor area high on the septum: crusting while it heals.
• Permanent loss of septal mucosa, which narrows the options if it fails.
• More frequent failure with a unilateral flap in large perforations.
• Long follow-up limited to the original series: extended and bilateral versions are recent.

1. 1Is there enough cartilage around my hole to raise this flap?
2. 2Unilateral or bilateral in my case, and why?
3. 3What mucosa would be left to mobilise if this technique failed?
4. 4How many AEA flaps have you raised, and with what follow-up?
5. 5How long will the donor area take to heal?

Write the answers down: they are what lets you compare two opinions.

Where it is done

Related techniques