A Surgical Strategy for Three-Layer Structure Reconstruction in Total Nasal Defect

Background/Objectives: Total nasal reconstruction has long represented a formidable surgical challenge. To date, no universally accepted, evidence-based protocol for nasal reconstruction exists to guide clinical practice. This study introduces a novel technique for comprehensive, three-layer nasal reconstruction. Specifically, the approach entails (1) reconstruction of the nasal mucosal lining using a free radial forearm flap; (2) provision of robust structural support via an exogenous extended framework; and (3) restoration of the external nasal skin using an expanded forehead flap. Methods: Ten patients underwent reconstruction for full-thickness nasal defects, all achieving successful structural and functional restoration. All surgical procedures were completed successfully, with operative durations ranging from 6.5 to 10.5 h. One patient developed an infection involving the rib cartilage graft. Following thorough debridement, the radial forearm free flap healed uneventfully. A second patient experienced postoperative vascular compromise of the flap. Intraoperative exploration revealed inadequate perfusion; immediate microsurgical revision—including adjustment of recipient vessels and/or re-anastomosis—successfully restored flap viability. Results: Primary wound healing was achieved in all patients within 10–22 days. All patients completed a follow-up of 12–36 months (mean: 21.5 months). Both patients and the surgical team rated postoperative nasal aesthetics as satisfactory. Objective functional assessments—including anterior rhinomanometry and peak nasal inspiratory flow—demonstrated no clinically significant impairment in nasal airflow. Conclusions: This surgical strategy for reconstructing the three-layer nasal architecture in patients with total nasal defects represents a rational and clinically viable approach—offering a valuable reference for rhinoplasty surgeons performing such complex reconstructions.