Background <p>Nasal reconstruction for total or subtotal defects remains challenging, necessitating aesthetic and functional restoration. Microsurgical reconstruction, particularly free tissue transfer, has significantly improved outcomes for these complex defects. This review aimed to assess the effectiveness of microsurgical methods in total and subtotal nasal reconstruction, documenting complications and long-term outcomes.</p> Methods <p>A systematic review adhering to PRISMA guidelines was conducted. Databases including Web of Science, Scopus, PubMed/MEDLINE, Ovid, EMBASE, and the Cochrane Library were searched. From the 431 initial articles, 16 met inclusion criteria, comprising case series, case reports, retrospective studies, and systematic reviews. Data collected included patient demographics, defect causes, surgical procedures, results, and adverse effects. Rayyan software facilitated data extraction and screening, with subsequent synthesis using Microsoft Excel.</p> Results <p>The radial forearm flap (RFF) was the most frequently utilized technique, primarily for defects caused by cancer and trauma. Common complications included partial flap necrosis (41%), infection (25%), and wound dehiscence (13%). Alternative flaps like the ulnar forearm flap (UFF), free auricular flap, and anterolateral thigh (ALT) flap offered advantages in specific cases, such as reduced donor-site morbidity. Precoating RFF with polyethylene or cartilage improved outcomes in complex scenarios.</p> Conclusions <p>Microsurgical techniques, especially RFF, are effective for reconstructing large nasal defects, offering adaptability for intranasal lining and structural support. While donor-site morbidity remains a concern, alternative flaps like UFF and ALT provide viable options. This review highlights the efficacy of microsurgical approaches in managing complex nasal defects. </p> <p>Level of Evidence: Not ratable</p>