Single‐Stage Three‐Layer Total and Subtotal Nasal Reconstruction: An Islanded Paramedian Forehead Flap, Hybrid Lining, and Titanium Support Framework

BACKGROUND: Total and subtotal full-thickness nasal defects require simultaneous reconstruction of the internal lining, structural framework, and external soft-tissue envelope. This study evaluated the clinical outcomes of a single-stage approach combining an islanded paramedian forehead flap, hybrid lining, and titanium miniplate framework. METHODS: We retrospectively reviewed 14 patients who underwent reconstruction of total or subtotal full-thickness nasal defects following oncologic resection between June 2020 and June 2025. The flap was transferred to the nasal defect through a subcutaneous tunnel. The internal lining was reconstructed using folded vascularized flap tissue combined with a split-thickness skin graft. Structural support was provided by longitudinal and transverse titanium miniplates secured at four bony fixation points. Patient-reported functional and aesthetic outcomes were assessed using the Nasal Appearance and Function Evaluation Questionnaire (NAFEQ). RESULTS: The mean patient age was 69 years (range, 55-94 years); 10 patients (71.4%) had at least one comorbidity, and 12 were classified as American Society of Anesthesiologists physical status III or IV. Eleven patients had total defects and three had subtotal defects. The mean flap dimensions were 7.6 × 5.8 cm. The mean reconstruction time was 57 min (range, 43-78 min), and the mean follow-up duration was 18 months (range, 14-24 months). Two complications occurred (14.3%): limited plate exposure and partial flap necrosis. Both were managed with debridement and primary closure without plate removal. No total flap loss, infection, wound dehiscence, nasocutaneous fistula, or clinical structural instability occurred. Postoperative computed tomography in 11 patients demonstrated no plate displacement, screw loosening, or fixation failure. No patient required pedicle division. Twelve patients completed the NAFEQ; the mean functional and aesthetic subscale scores were 22.5 ± 3.0 and 26.1 ± 6.1, respectively. CONCLUSION: The combined use of an islanded paramedian forehead flap, hybrid nasal lining, and a titanium framework secured at four fixation points may provide a single-stage reconstructive option for selected patients with total or subtotal full-thickness nasal defects. This approach may be particularly considered for patients in whom prolonged microsurgical reconstruction could impose an additional surgical and physiological burden because of advanced age or comorbidities, as well as for those who decline multistage reconstruction.