Introduction: Nasal septal perforation is a well-known complication of nasal cocaine abuse, affecting 5% of users. More extensive osteocartilanginous necrosis involving the nasal cavity and palate may lead to complete nasal loss and/or collapse. Reconstruction of these defects can be quite daunting with high complication rates owing to residual ischemic injury of the local nasal and paranasal soft tissues. Free tissue transfer for the management of these injuries can circumvent the problems of local tissue manipulation by providing unsullied, well-vascularized tissue. Purpose: To evaluate our results with the use of free tissue transfer for treatment of the cocaine injured nose. Methods: Over the past six years, 6 consecutive patients, aging 29-56 years (avg. 41 yrs) were treated by the senior author for nasal deformities due to cocaine abuse. Nasal deformities ranged from: isolated nasal septal perforation (N=1), total nasal lining loss (vestibule, floor, columella) (N=2), total nasal lining and upper lip/cheek loss (N=1), to total nasal loss (lining, external nose)(N=2). All patients abstained from cocaine use for at least one year prior to reconstruction. Patients were evaluated for aesthetic and functional surgical outcomes. Results: All patients were treated with radial forearm free flaps, either as multi-island flaps (N=3) or as prelaminated flaps (n=3). Two patients also underwent a paramedian forehead flap for reconstruction of the external nose. Each patient required 4-7 (Avg. 5.2) operative procedures to complete the reconstruction. All flaps were revascularized to the facial vessels. There were no flap losses. All donor sites were resurfaced with a full-thickness skin graft without incident. One patient suffered recurrence of a nasal septal perforation. There were no infections. All patients demonstrated patent nasal airways, improved nasal form, and were satisfied with their results. All patients remained drug free during the study period. Conclusions: In cases of loss of nasal lining and support due to cocaine injury, free tissue transfer obviates the reliance on compromised local tissues and provides a reliable means for reconstruction in patients who are drug free. In one of the largest series to date, we have found that the use of free tissue transfer is invaluable in the treatment of these conditions. The radial forearm flap is unique in its adaptability as an acute, multi-island flap or as a delayed, prelaminated flap. The various configurations of this flap allow for immediate thinning, accurate shaping and tailoring, maximizing the precision of the repair, while minimizing patient morbidity.