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Microvascular free flaps have proved to be highly reliable and efficacious for restoration of missing elements of the nasal lining and adjacent facial soft-tissue defects in total and subtotal nasal reconstruction. Combined with a forehead flap, this aesthetic approach allows for reconstruction of the center of the face layer by layer and facial unit by facial unit. Specific attention is paid to the artistic creation of normal nasal dimensions, proportion, and form using carved and assembled cartilage grafts and by secondary subcutaneous contouring. In addition, this technique produces a patent airway.

The nasal tip is a thin structure, often just 3 or 4 mm thick. There is little need to inform an audience of Mohs histographic surgeons that as a defect becomes progressively deeper it goes in the space of a few short millimeters from superficial to full-thickness perforation. Tissue defects of little significance to the structure and aesthetics of the nose (and requiring a simple solution) can at first glance look the same as defects of great significance. Attainment of the aesthetic result, rather than a merely reparative one, requires that the wound be analyzed anatomically and three-dimensionally, tissues be replaced in like kind, the wound be braced with a lamina of cartilage (or bone), the internal hard tissue framework be given a refined aesthetic shape (at Stage II), and the mantle of carefully selected donor skin and subcutaneous fat be a work of sartorial excellence.

Reconstruction of the nasal lining, alone, is a very challenging endeavor that demands careful surgical planning and precise technical execution. The use of microsurgical transfer for these defects allows considerable latitude for duplication of the missing complex three-dimensional anatomy and avoids sullying the adjacent facial soft tissues. Because of the adverse condition of the local tissues, the majority of these cases could not have been brought to a successful conclusion without the use of free tissue transfer, and this is particularly relevant in the cocaine-injured nose.