Sequential Paramedian Forehead Flaps for Nasal Salvage Reconstruction After Failure of a Folded Microvascular Forearm Flap

Summary: Subtotal nasal amputation poses significant reconstructive challenges, particularly in complex traumatic composite defects. The gold-standard Burget–Menick technique combines a radial forearm free flap (RFFF) for lining, rib cartilage framework for structural support, and paramedian forehead flap (PFF) for coverage. Although single-stage RFFF–PFF combinations have reduced operative time, the literature lacks clear salvage protocols for microvascular flap failure. We present a 43-year-old patient with a history of smoking with near-total nasal amputation following human bite trauma, in whom initial reconstruction using a folded RFFF, costal cartilage grafts, and a left PFF was complicated by partial RFFF necrosis due to venous thrombosis. The salvage strategy used sequential bilateral PFFs: the original left PFF was thinned and converted to a vascularized hinged lining, whereas a contralateral right PFF provided external coverage after Doppler confirmation of supratrochlear artery patency. Rib cartilage grafts reconstructed the structural framework, including alar struts, spreader grafts, and a septal extension graft. Despite requiring a skin graft at the second PFF donor-site (tissue expansion declined by the patient), 1-year outcomes demonstrated satisfactory aesthetic and functional results, with patent airways, natural contour, and no donor-site morbidity. This case illustrates that sequential PFFs can effectively salvage failed microvascular nasal reconstruction while preserving the original reconstructive goals. Key technical considerations include preservation of a vascular base during PFF conversion, preoperative Doppler assessment of contralateral flap perfusion, and strategic use of hinged flaps to optimize lining. This novel sequential PFF approach offers a viable alternative when primary reconstruction fails, particularly when tissue expansion is not feasible.