Complex Nasal Reconstruction: A Methodical Approach to the Three-Stage Paramedian Forehead Flap.

Complex nasal reconstructions require adequate planning with an accurate estimation of the time necessary to perform each stage. Reconstructions of the entire nose, multiple subunits, or a substantial subunit typically require lining replacement and cartilage grafting. Securing the lining prior to a staged reconstruction is preferred, but options such as the Menick folded paramedian forehead flap (PMFF) allow for lining coverage at the time of the first stage. The free radial forearm flap and the PMFF remain the gold standard for the initial lining coverage. Cartilage grafting is fundamental to complex nasal reconstructions and can be secured in either the first or the second stage. Staged reconstructions require thorough patient education, patience from both the patient and the surgeon, and an understanding that final revisions may be necessary.