Microsurgical Reconstruction of the Columella With a First Web Space Free Flap: A Case Report and Review of Techniques

Reconstruction of the columella, one of the smallest facial subunits, presents significant aesthetic and functional challenges due to its complex anatomy, limited local tissue for repair, and restricted vascularisation. Although many methods are described, literature on microsurgical solutions for complex secondary reconstructions, especially after conventional methods have failed, remains limited. This report introduces a tailored, single-stage approach that combines a first web space free flap from the foot with an iliac bone graft to provide both soft tissue coverage and structural support, while also reviewing other microsurgical techniques. A 24-year-old patient presented with a severe deformity, including a shortened columella, depressed nasal tip, and a scar extending to the right upper lip, causing alopecia in the mustache area due to a shrapnel injury during the Palestine War. After excising scar tissue and a necrotic L-strut from a previous failed surgery, a 2 × 3 cm columellar and septal defect was created. A fasciocutaneous free flap from the first web space of the foot was planned as a 2.5 × 4 cm rectangle, positioned transversely over the first web space and microsurgically transferred for end-to-end anastomosis to the angular artery and vein, then folded over an iliac bone graft to provide both external skin coverage and internal lining. The postoperative course was uneventful, and the patient was discharged on the fifth day. At the one-year follow-up, the reconstructed columella remained stable, and the patient expressed high satisfaction with the final aesthetic and functional results. This report shows that the first web space free flap, combined with a structural bone graft, offers a single-stage solution for complex columellar defects, providing a tailored approach when conventional methods have failed or are insufficient. The novelty of this approach lies in using an iliac bone graft, which offers strong and durable support capable of resisting scar contracture and maintaining long-term nasal tip projection despite heavily scarred tissue. Compared with other reviewed techniques, this single-stage approach avoids the multiple procedures required for prefabricated flaps and reduces donor site morbidity or bulkiness. Furthermore, its long vascular pedicle is an advantage over shorter-pedicled auricular or hand flaps, while the robust bone graft supplies a more durable framework against the contractile forces of compromised local tissue than cartilage-based reconstructions.