Background <p>Repairing nasal defects remains a significant challenge, and numerous flap designs have been proposed as potential solutions. The authors' team designed a new rotational advancement flap for improved aesthetic results and compared it with the now commonly used bilobed flap.</p> Methods <p>This is a randomized, evaluator-blinded, prospective study. One hundred twenty patients with nasal defects were randomly assigned to two groups: the rotational advancement flap (RAF) group (n = 60) and the bilobed flap (BF) group (n = 60). The two groups were similar in gender, age, and defect area. Thirteen patients have been lost to follow-up. To ascertain the safety, aesthetic outcome, scarring of the procedures, and early complications, the Likert scale (Likert), Vancouver Scar Scale (VSS), and Patient Satisfaction Scale (PSS) were scored to determine safety, aesthetic outcome, and scarring. Analyses were by intention-to-treat (ITT) analysis using multiple imputations for missing outcome data and compared with Per-protocol (PP) analysis.</p> Results <p>The rate of early complications was higher in the BF group than in the RAF group (<i>p</i> &lt; 0.05). The results of the PP analysis showed that the Vancouver Scar Scale scores of the RAF group were significantly better only in terms of scar height (<i>p</i> &lt; 0.05). The rest of the three groups had no significant difference (<i>p</i> &gt; 0.05). The RAF group's Likert and PSS scores reflected better aesthetic results (<i>p</i> &lt; 0.05). These results are consistent with the ITT analysis.</p> Conclusion <p>The lateral rotational advancement flap is an aesthetic and reliable repair for medial nasal defects.</p> Level of Evidence III: <p> Therapeutic study. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors <a href="http://www.springer.com/00266">www.springer.com/00266</a></p>