Simultaneous free flap and forehead flap for nasal reconstruction

Background: Reconstruction of total or near-total nasal defects is challenging and requires the re-creation of three nasal layers. Fasciocutaneous free flaps have been used effectively for restoring the vascularized nasal lining and staged forehead flap for nasal skin replacement, which is a long process. The aim of this study is to share our experience of combination of preliminary free tissue transfer with paramedian forehead flap reconstruction in the same stage of complex nasal reconstruction. Methods: From December 2015 to July 2021, 10 patients underwent nasal reconstruction with free flaps including 4 medial sural artery perforator (MSAP) flaps, 5 anterolateral thigh (ALT) flaps and 1 radial forearm flap for lining and forehead flaps for skin coverage simultaneously for total or subtotal nasal defects. Nasal obstruction symptoms evaluation (NOSE) score was utilized to evaluate the functional outcome and the aesthetic results were evaluated with the last follow-up photos with score 1–5 by 5 plastic surgeon and 5 laypersons. Results: The size of the free flaps ranged from 3 cm x 6 cm to 6 cm x 13 cm. After excluding one patient who expired before forehead flap division due to comorbidities, the average duration between combination surgery and the division of the forehead flap pedicle of the remaining patients was 5.7 months (range, 2–12). For patients without any postoperative events, the duration was 2.2 months (range, 2–3). One free flap had partial necrosis due to infection. The average follow-up duration was 29.6 months (range, 12–64). The NOSE score was 5.9 (range, 0–10) and the aesthetic score is 4.1 (range, 3–5) in average. Conclusions: The combination of preliminary free tissue transfer for nasal lining restoration with a paramedian forehead flap for nasal skin replacement in the same stage may shorten the long process and achieve satisfactory reconstruction in complex nasal reconstruction.