The Role of Microsurgical Free Flap in Complex Nose Defect Reconstruction

Nasal reconstruction, involving a central facial structure with complex three-dimensional contours and essential respiratory function, continues to evolve. The principal challenge lies in simultaneous restoration of the three essential components-external skin cover, skeletal support, and a vascularized internal lining-often across multiple aesthetic subunits. This review summarizes a decade of clinical experience at Chang Gung Memorial Hospital, focusing on the evolution of reconstructive strategies in 150 patients with total or subtotal composite nasal defects. Particular emphasis is placed on the incorporation of microsurgical free flaps to enhance both aesthetic outcomes and reconstructive efficiency. This chronologically structured review highlights four major advances: (1) refinements of the paramedian forehead flap (PFF), including a T-shaped design for improved biomechanical stabilization in columellar reconstruction; (2) application of vascularized lining using the folded ulnar forearm flap (FUFF) and lower-extremity free flaps, including the anterolateral thigh (ALT) and medial sural artery perforator (MSAP) flaps; (3) integration of digital technologies, including computer-aided design (CAD) and three-dimensional printing, to improve nasal symmetry; and (4) implementation of an expedited protocol involving simultaneous free flap and PFF transfer to facilitate physical and psychosocial recovery. The T-shaped PFF design demonstrated superiority in preventing columellar dehiscence. For internal lining, the FUFF provided thin and pliable coverage with minimal donor-site morbidity; however, lower-extremity flaps (ALT/MSAP) offered enhanced long-term passive structural support, reducing the risk of airway collapse. Digital planning with three-dimensionally printed templates resulted in significantly improved postoperative symmetry in heminasal reconstructions ( p  < 0.05). Simultaneous free flap and PFF transfer proved safe and significantly shortened overall treatment duration. Psychosocial assessments revealed a reduced duration of postoperative distress, underscoring the clinical importance of procedural efficiency. Successful contemporary reconstruction of complex nasal defects requires a specialized, multimodal approach. Optimal long-term aesthetic and functional outcomes are achieved through the synergistic application of refined PFF techniques, appropriate selection of vascularized lining free flaps, and routine use of digital technologies for surgical planning.