Alternative Nasal Reconstruction Technique Using a Paramedian Forehead Flap and Intranasal Full-Thickness Skin Graft in a Patient With Recurrent Basal Cell Carcinoma and Previous Contralateral Forehead Flap: A Case Report

The nose is one of the facial regions most commonly affected by skin cancer, and its reconstruction represents a dual aesthetic and functional challenge. When defects involve more than 50% of a subunit or multiple aesthetic units, reconstruction requires thin, flexible tissue with reliable vascularity. The paramedian forehead flap remains one of the most versatile options, particularly in recurrent tumors, where achieving clear margins and restoring nasal patency is essential. A 54-year-old male with a history of solid infiltrative basal cell carcinoma of the right nasal ala, previous paramedian forehead flap reconstruction, and positive margins underwent evaluation. Comorbidities included HIV with an undetectable viral load, diabetes mellitus type 2, hypertension, alcoholism, and smoking. Examination revealed a 10 × 15 mm, pearly, ulcerated lesion with telangiectasias. After tumor excision, a paramedian forehead flap was designed and elevated with a 2-cm vertical pedicle. A retroauricular full-thickness skin graft was fashioned into a tubular structure and sutured to the healthy nasal vestibule to re-create the right neovestibule. The flap was inset through an opening in the forehead flap, and a cotton-filled glove finger was placed intranasally for support. The patient progressed favorably with adequate flap vascularization. Paramedian forehead flaps remain the gold standard for large nasal defects due to their axial blood supply and color match. The addition of tubular full-thickness grafts expands their applicability in complex vestibular reconstruction, with literature supporting their reliability and functional outcomes. This case highlights a versatile technique combining a paramedian forehead flap with a tubular full-thickness graft to restore nasal contour and vestibular patency. It represents a reproducible strategy for complex nasal reconstruction with promising early aesthetic and functional results.