Tunneled paramedian forehead flap for a composite nasal sidewall to medial cheek defect

Composite facial defects represent complex reconstructive challenges. Complicated reconstructions like these are not uncommon after skin cancer excisions, as these tumors often affect the head and neck. In addition to technical considerations, minimizing morbidity is an important aspect of planning surgical reconstructions in patients of advanced age and those with barriers to medical care. Herein, we discuss the successful application of a tunneled paramedian forehead flap for a composite defect involving the nasal sidewall, medial canthus, and medial cheek alongside a second defect on the ipsilateral cheek. Our 92-year-old patient presented with 2 large basal cell carcinomas that were treated with Mohs micrographic surgery, resulting in a 2.5 cm defect at the medial canthus and a 1.2 cm defect at the lateral cheek. The tunneled paramedian forehead flap achieved excellent cosmesis with a preserved nasofacial sulcus and avoidance of ectropion while also conveying less morbidity than alternative reconstructive options.