Background
Reconstruction of total or near-total nasal defects is challenging and requires the re-creation of three nasal layers. Fascio-cutaneous 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. This is the largest case series presenting a combination of preliminary free tissue transfer with paramedian forehead flap reconstruction in the same stage of complex nasal reconstruction.

Methods
From December 2015 to October 2020, 9 patients underwent nasal reconstruction with free flaps and forehead flaps simultaneously for total or subtotal nasal defects. The etiology of the nasal defects was including malignancies, trauma, and congenital defect. All patients had composite nasal defects involved in both the nasal lining or nasal floor and multiple nasal subunits. Free tissue transfer was utilized for nasal lining or floor reconstruction, Framework reconstruction with either rib cartilage or concha cartilage was performed, and Staged forehead flap reconstruction was performed based on aesthetic subunit principles.

Results
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 5.8 months (range, 2-12). For patients without any postoperative events, the duration was 2.3 months (range, 2-3). The average follow-up duration was 24.9 months (range, 7-60). All the patients were satisfied with both the functional and anesthetic outcomes.

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 more efficient reconstruction in complex nasal reconstruction, and the patients were satisfied with both function and anesthetic outcome.

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