Importance: Medium and large nasal defects are mostly addressed with paramedian forehead flap reconstruction. The superior extended nasal myocutaneous island (SENMI) flap offers an alternative that can be single stage and can avoid a gross deformity. Objective: To describe a new flap for nasal reconstruction of medium and large nasal defects and to define the flap's limitations and indications. Design, Setting, and Participants: This original study was a retrospective case series of patients who underwent SENMI flap reconstruction from 2008 to 2018 at a private tertiary referral center-Skin Cancer and Reconstructive Surgery Center (SCARS Center). Participants included all consecutive patients of the senior author who had undergone SENMI flap from September 2012 to December 2018, consisting of 53 patients. Indications for surgery were mostly skin cancer defects, postreconstructive, and post-traumatic deformities. IRB approval was obtained from the St. Joseph Health Center for Clinical Research. Main Outcomes and Measures: The location of the defects was defined. The vertical length of flap advancement was measured. Number of stages required to achieve functional and aesthetic goals was reported. Appearance rating after the first stage was assessed. Results: A total of 53 patients [mean age 68 (range 30-92) years; 26 (49%) female and 27 (51%) male] were included in the case series. Reconstructed areas included 8 in the upper two-thirds of the nose (dorsum and sidewall), 34 in nasal tip, 32 in nasal ala, 12 in soft tissue triangle and infratip, and 13 full thickness defects of the alar rim. The flap advancing distance defined the nature of flap mobility. Of 53 patients, 41 had up to 2.0 cm of flap advancement and 12 had 2.0 to 3.2 cm of advancement. Of 52 patients aesthetically evaluated, 43 had mild or no detectable shape deformity on photographic evaluation after one stage. Single stage was performed in 25 patients, two stages in 21 patients, and three stages in 7 patients. Functional nasal valve stenosis was present in 18 patients (33%) after one stage. Partial flap ischemia occurred in two patients (4%). Conclusions and Relevance: SENMI flap is an effective technique for nasal reconstruction. It offers a single- or two-stage alternative with less temporary deformity in comparison with forehead flap reconstruction.