full thickness skin grafts and a concomitant three-stage forehead ap technique [14]. A full thickness skin graft is designed for the lining defect and sutured in place [14]. A forehead ap is utilized and transferred into the defect providing the vascu­lar supply to the skin graft [14]. During the second, intermediate stage, the plane between the frontalis and subcutaneous tissue is dissected in the area of the middle and upper thirds, and structural grafting is placed [14]. Inset completion, soft tissue sculpting, and pedicle division are then completed during the third stage 3weeks later.

In cases of extensive unilateral lining defects where the nasal mucosal ap options are depleted, or in cases of bilateral nasal defects, options to restore the nasal lining include skin grafting, dual forehead aps, or free tissue transfer. In these larger defects requiring extensive structural grafting, skin grafts have many disadvantages and typically are not an option. Both the anterolateral thigh fascial ap and the radial forearm free ap have been described with good outcomes in reconstructing lining defects in total nasal reconstruction while concomitantly using paramedian forehead aps for the external defect [8, 10, 15].

When assessing a nasal defect, there are multiple variables to consider prior to designingand nalizing a reconstruction plan. An interview with the patient should explore prior satisfaction with nasal appearance, prior photos of the patient before the current deformity, and patient expectations. A discussion of the various options and advantages/disadvantages must be had. The surgeon should begin to visualize the planned outcome and the steps necessary to obtain that outcome [22]. The patient should then be prepared for the reconstructive process, particularly staged procedures that often times require weeks of deformity that the patient may nd unacceptable for public appearance. One of the rst variables that should be assessed is to determine if the defect extends into the adjacent lip, cheek, or periorbital sub­units. If the defect does extend into adjacent facial subunits, these should be recon­structed rst in order to restore the nasal platform prior to embarking on the nasal reconstruction [22]. The nasal subunits should be carefully evaluated [18, 22]. If the defect involves more than 50% of a convex subunit, particularly the tip or alar sub­units, excision of the remaining portion of that subunit should be considered, paired witha reconstruction that resurfaces the entire subunit [18, 22]. This prevents scar­ring and trap door defects within subunits, adeformity that is more noticeable when looking at an individual’s face. When examining a defect, it can be helpful to outline the nasal subunits.