CASE REPORT Microvascular reconstruction of the columella using a small radial forearm free flap: a case report Rossella Sgarzani & Luca Negosanti & Claudio Marchetti & Riccardo Cipriani Received: 19 March 2009 / Accepted: 13 July 2009 / Published online: 1 August 2009 # Springer-Verlag 2009 Abstract Columellar defects can result from various causes, a number of methods have been described for the reconstruc- tion using local, regional, or free flaps. When local tissues are not available due to the presence of scars, free flaps become the treatment of choice. We present the case of a columellar defect resulting from a distal necrosis of a forehead flap in total nasal reconstruction. The columella was reconstructed using a small radial forearm free flap and a conchal cartilage graft. The flap and the graft survived completely with a satisfactory cosmetic result and good respiratory function during the follow-up time of 2 years. The result was achieved in a single-stage operation: the patient did not need any further procedures to improve the nasal appearance. We propose that the radial forearm free flap may be an easy and reliable alternative among the surgical options for columellar defects when local tissues are not available. Keywords Columella defect . Reconstruction . Radial forearm free flap . Microsurgery Introduction The columella is an important cosmetic part of the nasal pyramid, located between the two nostrils and over the caudal side of the septal cartilage. It consists of a pair of fine textured crural cartilages and thin skin coverage. Columella defects can result from various causes including congenital absence [1], trauma, tumors, and distal necrosis of forehead flap in total nasal reconstruction [2]. Columella reconstruction is a challenge because the regional anatomy does not allow optimum reconstruction with local flaps. Although a number of methods are available (including skin grafts, local flaps, regional flaps, and free flaps), a single-stage treatment that ensures satisfactory shape, texture, and color match has not been described. In this case, we used a small radial forearm free flap and a conchal cartilage graft to reconstruct a complex columella defect. Methods A 62-year-old man presented with a recurrent basal– squamous cell carcinoma of the nasal pyramid, which extended to the left cheek. It had previously been treated with radiotherapy (Fig. 1). The patient underwent a wide total rhinectomy with partial excision of the left maxilla and overlying soft tissues (Fig. 2). In the same operation, the left maxillary defect was reconstructed with an anterolateral thigh (ALT) free flap, and a tissue expander was inserted in the forehead. After 3 months of forehead expansion, a total nasal reconstruction was performed: two nasolabial flaps and the rotation of part of the ALT flap allowed reconstruction of the lining, an iliac crest bone graft was used to restore structure, and the expanded forehead flap for cover (Fig. 3). The total nasal reconstruction was initially satisfactory, but after an initial distal congestion, the columella necrosed R. Sgarzani (*) : L. Negosanti : R. Cipriani Plastic Surgery Unit, S. Orsola Malpighi Hospital, via Massarenti n. 9, 40138 Bologna, Italy e-mail: rossellasgarzani@libero.it C. Marchetti Maxillofacial Surgery Unit, S. Orsola Malpighi Hospital, via Massarenti n. 9, 40138 Bologna, Italy Eur J Plast Surg (2009) 32:323–326 DOI 10.1007/s00238-009-0355-2