Pediatric Nasal Tip Reconstruction After a Donkey Bite Using an Expanded Paramedian Forehead Flap With Conchal...

Pediatric nasal reconstruction is challenging because it requires restoration of the external skin cover, structural support, and internal lining while taking into account facial growth and long-term aesthetic outcomes. Animal bite injuries may further complicate reconstruction because they often cause contaminated, irregular, composite tissue loss. We report the case of an eight-year-old boy who presented one year after a donkey bite with a 4 × 2 cm full-thickness nasal tip defect involving the medial portions of both alae, the anterior columella, and the anterior septal region. The child had loss of nasal tip projection, alar retraction, exertional nasal obstruction, and psychosocial discomfort. Reconstruction was performed in stages using a right paramedian forehead tissue expander, bilateral vestibular hinge flaps for internal lining, conchal cartilage grafts for alar support and columellar projection, and an expanded paramedian forehead flap for external skin coverage. Pedicle division was performed 25 days after flap transfer. The postoperative course was uneventful. At six months of follow-up, nasal breathing was normal, nasal tip projection was satisfactory, and no stenosis or secondary revision was required. A pressure-related frontal bony imprint caused by the tissue expander was noted intraoperatively and showed marked spontaneous regression after expander removal. This case highlights the value of a staged expanded paramedian forehead flap in selected pediatric patients with full-thickness nasal defects and limited forehead laxity. It also emphasizes the importance of reconstructing all three nasal layers and discussing the possibility of pressure-related cranial remodeling with families before pediatric forehead expansion.