Adaptive multi-stage paramedian forehead flap for nasal reconstruction following HSV-related necrosis in a pediatric patient with primary immunodeficiency

Large nasal defects in children are rare and create significant reconstructive challenges due to limited donor tissue, ongoing facial growth, and higher perioperative risks. These challenges are amplified in immunocompromised pediatric patients, particularly when infections such as herpes simplex virus (HSV) contribute to tissue destruction. The paramedian forehead flap is a reliable option for major nasal reconstruction in adults, but its use in children remains uncommon. We report a 4-year-old girl with an undiagnosed primary immunodeficiency and recurrent HSV infection who developed a full-thickness defect of the right nasal ala with partial auricular loss. A staged reconstruction was performed adaptively over five stages, including flap elevation with delay, transposition with native nasal skin lining and Matriderm application to reduce wound burden, partial division with alar sculpting, and final inset with eyebrow reconstruction. Intraoperative indocyanine green angiography confirmed adequate flap perfusion at each stage. The patient’s postoperative course was uneventful, and she demonstrated improved nasal airway patency, stable alar contour, and high parental satisfaction with cosmetic outcomes. This case suggests that a tailored, multi-stage paramedian forehead flap reconstruction may be safely performed in young children with complex nasal defects, including those with undiagnosed primary immunodeficiency and recurrent HSV infection, though further experience is needed to validate this approach. Careful staging, vascular assessment, and multidisciplinary collaboration were central to achieving successful functional and aesthetic results.