Local and free flaps in cutaneous nasal oncologic reconstruction

Reconstruction of cutaneous nasal defects following resection of sinonasal malignancies remains a complex surgical challenge because of the nose's intricate anatomy and its critical aesthetic and functional roles. Multiple reconstructive options are available to restore nasal integrity; however, no universally accepted optimal approach exists. This review summarizes contemporary approaches to oncologic nasal reconstruction using local, regional, and free flaps, with emphasis on the aesthetic subunit principle as the foundation of surgical planning. Reconstructive decision-making is guided by defect size, depth, and subunit involvement, as well as patient-specific factors such as comorbidities, prior irradiation, and the anticipated need for adjuvant therapy. Local and regional flaps, including the nasolabial flap and the paramedian forehead flap, are preferred for small to moderate cutaneous nasal defects, whereas free flaps, particularly the radial forearm flap, provide reliable solutions for extensive composite defects. Immediate reconstruction is generally associated with superior aesthetic, functional, and psychosocial outcomes; however, delayed reconstruction may be appropriate in selected cases requiring margin surveillance or additional oncologic assessment. This review aims to provide practical insights into reconstructive decision-making based on the available literature and clinical experience, with the goal of optimizing aesthetic, functional, and oncologic outcomes in patients undergoing oncologic nasal reconstruction.