Paramedian forehead flap (PMFF) reconstruction remains the gold standard for complex nasal defects, but donor site closure under tension risks dehiscence and poor scarring. This study quantifies closure forces for PMFF donor sites and evaluates force reduction achieved with coronal advancement flaps. Fifteen fresh cadaveric specimens were randomized to 3 groups based on the flap width (1.5, 3, or 4.5cm). Using a 6-degree-of-freedom robotic system, forces required for primary closure, hemicoronal advancement, and bicoronal advancement were measured. Force comparisons across closure techniques were analyzed using the Friedman test with post hoc Wilcoxon signed-rank tests. Primary closure forces averaged 9.1±0.4N, 29.0±4.2N, and 47.3±6.8N for 1.5, 3, and 4.5cm defects, respectively. Suture failure occurred in 80% of 4.5cm defects before achieving primary closure. Hemicoronal advancement reduced forces by 42% to 64%, and bicoronal advancement reduced forces by 77% to 86% compared with primary closure. Friedman analysis confirmed significant differences in closure forces across techniques (χ²=10.0, P=0.0067), while Wilcoxon pairwise comparisons showed consistent trends toward lower forces with advancement flaps, though not statistically significant due to small sample size. Coronal advancement flaps provide a substantial biomechanical advantage for PMFF donor site closure. Statistical analysis supports observed trends of tension reduction, reinforcing the clinical benefit of hemicoronal and bicoronal flaps for moderate to large defects.

Assessment of paramedian forehead flap perfusion using indocyanine green and near-infrared fluorescence-guided imaging.

To assess the risk of persistent opioid use after forehead flaps with preserved vascular pedicles. This multi-center cohort study used the TriNetX, LLC US Collaborative Network to identify patients undergoing forehead flaps with preservation of the vascular pedicle. Patients were grouped based on whether they received an opioid prescription within 1 week of surgery. Propensity matching controlled for age, race, sex, pain diagnoses, and previous opioid use. Baseline characteristics were analyzed with t-tests and chi-squares. Risk ratios assessed associations between variables and development of new persistent opioid use (new opioid prescription 3-9 months after forehead flap reconstruction). Overall, 7214 patients (3280 female [45.5%]) underwent forehead flap reconstruction with preservation of the vascular pedicle and 2660 (36.9%) receive a postoperative opioid prescription. Unadjusted analysis demonstrated a statistically significant association between gender and receipt of a postoperative opioid prescription, with male patients more likely than female patients to receive an opioid prescription (χ2 = 14.94, P < .001). After propensity score matching, 1352 patients (588 women [43.3%]) with a mean (SD) age of 67.3 (14.7) years, were included for analysis. Patients who receive a postoperative opioid prescription were at 3.21 times greater risk of developing new persistent opioid use compared to patients not prescribed postoperative opioids (RR = 3.21; 95% CI (2.27, 4.52)). Patients who receive postoperative opioid prescriptions after forehead flap reconstruction may be at greater risk of developing new persistent opioid use.

We describe a novel application of the nasal Superficial Musculoaponeurotic System flap for medial orbital wall reconstruction following orbital exenteration. A 64-year-old woman underwent type IIa exenteration for moderately differentiated squamous cell carcinoma of the right medial canthus, requiring resection of the lamina papyracea. A pedicled nasal Superficial Musculoaponeurotic System flap incorporating perichondrium and based on the dorsal nasal artery was harvested through a midline nasal incision to close a 1.5-cm communication between the orbit and nasal cavity. To provide additional stability and coverage, a contralateral supratrochlear artery-based paramedian forehead flap was employed. Postoperative evaluation confirmed flap viability and satisfactory anatomical separation between the orbit and nasal cavity. To our knowledge, this is the first reported use of a nasal Superficial Musculoaponeurotic System flap in orbital reconstruction. This case highlights its potential as a reliable and well-vascularized option for selected medial orbital wall defects.

Introduction: The purpose of this systematic review is to assess postoperative outcomes of the expanded forehead flap (EFF) for nasal reconstruction in East Asian patients, focussing on both functional restoration and aesthetic satisfaction in a population with unique anatomical considerations. Methods: A systematic review was performed using PubMed, MEDLINE, Embase, and Scopus databases by 4 independent reviewers. Articles were included if they focussed on the use of an expanded forehead flap for nasal reconstruction in East Asian patients, with outcomes related to complications, aesthetic satisfaction, and functional results. Studies published in English between 1995 and 2025 were considered. Results: The literature search yielded 68 initial articles. After duplicates of articles were removed, 50 articles underwent title review. Thirty-six articles underwent screening, and 32 articles were approved for full-text review. Twelve studies were deemed appropriate for inclusion in the systematic review. Conclusion: The expanded forehead flap is an effective and reliable procedure for nasal reconstruction in East Asian populations, offering both functional and aesthetic improvements. However, complications such as colour mismatch, hypertrophic scarring, and flap vitality issues must be carefully managed. Further studies with standardized outcome measures can continue to refine surgical techniques and minimize complications, ensuring better long-term patient satisfaction.

Background: Patients undergoing nasal reconstruction with the paramedian forehead flap (PMFF) can lead to scalp hair transfer and brow distortion. To minimize this, we have adopted the low median forehead flap (LMFF). Objectives: To compare the hypothetical flap reach of the LMFF with the PMFF and measure flap viability and hair transfer amongst patients undergoing nasal reconstruction. Materials and Methods: A multi-institutional retrospective chart review of patients undergoing the LMFF collected demographics, flap viability, brow distortion, and hair transfer. Photograph measurements compared the hypothetic flap reach between an LMFF or PMFF design. Results: Eighty patients (mean age 65 ± 13 [SD] years, 56.3% female) met inclusion after LMFF for nasal defects, mostly from skin cancer resection (93.8%) involving the tip (67.1%) and ala (73.4%); with ≥3 involved subunits (63.8%). Transferred scalp hair (n = 1, 1.3%), and no flap compromise occurred. In photograph analysis, the LMFF showed an 11.6% increase in flap reach as compared to the PMFF (p < 0.0001). Intra-rater and inter-rater variances were nonsignificant. Conclusions: The LMFF is a viable modification to the PMFF for nasal reconstruction, especially in patients with short hairline and/or distal nasal tip/alar defects where increased flap reach and minimal hair transfer are desired.

The frontonasal flap is a versatile, single-stage local cutaneous flap used for reconstruction of nasal tip and alar defects, most commonly following oncologic resection or trauma. Harvested from the nasal dorsum and glabellar region, it benefits from the robust vascular network of the upper nose, allowing safe transposition with predictable outcomes. Proper flap design—adapted in size, curvature, and scar placement—enables tailored reconstruction according to defect location, laterality, and patient-specific anatomy. Compared with larger axial flaps such as the paramedian forehead flap, the frontonasal flap offers a less invasive option for select defects, avoiding multistage reconstruction. Reported complication rates are low, with high aesthetic and functional satisfaction. This article reviews the indications, design principles, advantages, limitations, and current evidence surrounding the frontonasal flap, emphasizing its role as a reliable alternative in nasal reconstruction.

The most common complication after interpolated forehead flap repair is postoperative bleeding from the pedicle. Reconstructive surgeons should focus on minimizing postoperative bleeding while ensuring the blood supply and integrity of the flap are preserved. To provide a comprehensive review of the various methods to reduce the risk of bleeding after interpolated forehead flap repair. A comprehensive literature review of PubMed articles discussing strategies to reduce postoperative bleeding specifically in interpolated forehead flap repair was performed. A total of 9 unique techniques were apparent from the literature, including use of hydrophilic polymer and potassium ferrate, ferric subsulfate 20% solution, oxidized regenerated cellulose gauze, gelatin sponges, thrombin-based hemostatic agents, aluminum chloride, cyanoacrylate, skin graft, and tranexamic acid. Reconstructive surgeons should be knowledgeable of the various techniques to reduce bleeding after interpolated forehead flap repair, as bleeding can result in patient dissatisfaction and often requires intervention. Each technique identified in the literature offers its own advantages and drawbacks; its choice should be tailored to the needs of each patient.

48 Three-stage tertiary nasal reconstruction using a paramedian forehead flap following mutilation owing to failed previous attempts: a case report

Bioresorbable hyaluronate-carboxymethylcellulose membranes (HA membrane) have been applied to prevent adhesion formation following gynecologic and abdominal procedures. However, the use of HA membrane to enhance flap delay has not been well described. We present a novel application of HA membranes as barriers in delayed flaps for reconstructive surgery. All cases where HA membrane was utilized as a barrier to separate the undersurface of the flap from its respective wound bed during a delay procedure by the senior surgeon were reviewed. Indications for use of the HA membrane included patient risk factors, flap selection, or wound size. The HA membrane was used in 4 patients undergoing flap reconstruction with a delay procedure. Flaps included were the reverse sural fasciocutaneous flap, trapezius myocutaneous flap, and 2 paramedian forehead flaps. All of the donor wound beds showed no residual HA membrane and no tissue adherence, thus allowing minimal repeat dissection. All flaps were viable without signs of infection. All of the flaps in this study healed without any complications. There were no instances of infection, venous congestion, or delayed wound healing. HA membranes can safely serve as degradable barriers in flaps undergoing the delay phenomenon. We speculate that HA membrane reduces reestablishment of microvascular network between the flap and its wound bed and may contribute to augmentation of the remaining circulation within the delayed flap.

Paramedian forehead flap for nasal reconstruction in sclerodermiform basal cell carcinoma

The paramedian forehead flap (PMFF) is a longstanding, versatile technique used in nasal reconstruction offering robust vascularity and excellent aesthetic outcomes. While the donor site is usually closed primarily, tension can make this challenging and may create widened scarring or dehiscence. A retrospective review of 108 patients undergoing PMFF following an excision of a basal or squamous cell carcinoma between January 2015 and December 2023 by a single surgeon was performed. Size of defect, location, postoperative complications, scar quality, and analysis using the validated Patient and Observer Scar Assessment Scale (POSAS) were used to assess patient satisfaction with their donor site scar. The PMFF donor site was closed primarily in 50.9% of patients, with a skin graft in 16.7% and with a hemicoronal flap in 32.4%. Primary closure exhibited higher complication rates (wound dehiscence, alopecia) in medium defects (2-4cm) and worse cosmesis (POSAS 40) compared with small defects <2cm (POSAS 15). Skin grafting showed the worst cosmesis (POSAS 42) despite no complications. The hemicoronal flap group demonstrated the best cosmesis (POSAS 9 for medium defects and 14 for large (>4cm) defects) and no complications, suggesting superior scar quality and minimal tension. The hemicoronal flap shows promise in decreasing wound tension and improving the scar quality in PMFF. This helps decrease complications associated with high wound tension as well as increase patient satisfaction in their scar.

Large nasal defects after dog bites are a complex problem, the solution of which is possible provided that the optimal choice of skin graft and professional performance of surgical intervention are carried out as soon as possible after the injury. Aim. To determine the feasibility of using a rotational paramedian full-thickness forehead flap for the reconstruction of nasal defects after a dog bite. Material and Methods. Over the course of six years (2017-2023), 6 victims with bite wounds on the nose were brought to Lviv regional hospital for war veterans and victims of repression named after Yurii Lypa in Lviv by ambulance, 4-7 hours after receiving the injury. All patients were male, aged 22 to 51 years. Due to the lack of documented information on vaccinations, all patients received passive tetanus prophylaxis. In accordance with current guidelines, animal bites have been reported to the appropriate services. The primary surgical treatment of the wound was carefully performed (washing with isotonic sodium chloride solution, removal of blood clots, non-viable tissue parts, decontamination of the skin with soap solution and aqueous iodine), which created the opportunity to inspect the wound to its full depth. No bone or cartilage damage was found in any case, but the soft tissue defect was significant. All victims underwent surgery during the first day of their stay in the clinic under endotracheal anesthesia. The duration of the intervention is 91-210 minutes. The administration of broad-spectrum antibiotics was started before surgery and continued for 5-7 days. The postoperative period was without complications. Graft engraftment was achieved in every case. The cosmetic final result did not cause any concerns in all patients. Results. The patients underwent classical two-stage surgical treatment. The first plastic surgery was performed with a paramedian forehead flap. The choice of donor site was determined by the proximity of the forehead skin to the color and texture of the nose. In addition, the edges of the forehead skin after graft extraction, being mobilized by sharp and blunt methods, can be sutured without tension. We consider the determination of a graft of sufficient size and shape (not larger and in no case smaller) to be a difficult part of the operation. We consider tissue tension to be an unacceptable mistake that can lead to tissue necrosis, suppuration, and therefore an unsatisfactory cosmetic result. After thorough hemostasis, the wounds were closed with knotted sutures (Prolene 4-5.0). The second stage of soft tissue rhinoplasty was the excision of the feeding pedicle on day 30-35. Discussion. A dog bite is one of the most common types of animal bites. It accounts for between 26.8% and 56.5% of head and neck injuries. About 1-2% of bite patients require hospitalization. The most common bite site on the head and neck is the upper lip - 37.8%, the nose - about 20.6%. Surgery using a forehead flap takes less time, does not limit the patient's mobility after surgery, and does not restrict food intake, unlike reconstructive surgeries in which flaps from other parts of the body, such as the forearm (Italian plastic), are used to close soft tissue defects in the nose, which takes more time than forehead surgery, limits the patient's body movements for a certain period after surgery, and requires more stages to achieve a good aesthetic appearance. In summary, the surgeon reconstructing the nose after a dog bite should consider the possibility of using a frontal flap as a key surgical method. Conclusion. Bite wounds to the nose vary in shape, size, and depth of the defect. Reconstruction of large soft tissue nasal defects after dog bites with a frontal rotational graft gives good long-term results if performed professionally.

Tunneled flaps reconstruction after facial tumor resection: Retrospective study and new forehead flap

The paramedian forehead flap is a versatile and widely used reconstruction technique for nasal defects. Although it can provide excellent aesthetic outcomes, the medial brow can be disrupted, leading to facial asymmetry and patient dissatisfaction. We describe a simple and reliable surgical technique for medial eyebrow reintegration performed at the time of forehead flap pedicle division. Between 2015 and 2024, 146 patients underwent medial eyebrow reconstruction using this technique at the time of their pedicle division. During the second stage of the forehead flap during pedicle division, a standardized technique using a semicircular incision and flap inset was employed to reposition the medial eyebrow into continuity with the remaining brow. Patient outcomes were assessed through follow-up visits, and aesthetic outcomes were reviewed descriptively. One hundred forty-six patients underwent eyebrow reconstruction using this method at the time of the division of their forehead flap. All patients achieved natural-appearing medial-to-lateral brow continuity with high levels of satisfaction. Minor revisions were required in a limited number of cases including sensitive neuroma, and contour deformities. This reconstruction technique allows for reliable aesthetic restoration of the medial eyebrow after forehead flap reconstruction. It can be easily incorporated into standard practice during pedicle division and improves symmetry and patient satisfaction.

Novel flap designs for reconstructing the exenterated orbital cavity - A systematic review.

The nose is not only an important part of human appearance but also performs important functions, including olfaction, humidification, and breathing. The history of nasal reconstruction dates back to 600 BC (Sushruta, India), and the Indian method using a forehead flap remains to this day the criterion standard for large defects. The art of nasal reconstruction has travelled across many countries and continents and benefited from their surgical contributions. An understanding of nasal subunits, arterial anatomy, and knowledge of skin zones is critical in planning any reconstruction. A stepwise logical planning process helps in deciding the right choices for reconstruction. It is vital to recreate all three layers of the nose, namely skin, skeletal support, and nasal lining. Local nose and facial flaps form the backbone of nasal reconstruction. Skeletal support is vital to providing shape and stability to any nasal construct. Nasal lining restoration is important for maintaining the patency of the airways. Patience, persistence, and the use of reliable techniques can make nasal reconstruction a predictable and rewarding experience for every plastic surgeon

Reconstruction of Two Independent Facial Defects Using a Single Paramedian Forehead Flap: Comment.

Staged interpolation flaps remain central to reconstructing complex facial defects, with traditional pedicle takedown occurring approximately 3 weeks postoperatively. However, prolonged pedicle duration may cause patient discomfort and impair quality of life. To evaluate the safety and outcomes of early takedown (<21 days) versus conventional takedown (≥21 days) across 3 commonly used interpolation flaps: postauricular, melolabial, and paramedian forehead. Retrospective cohort study including patients who underwent one of the 3 interpolation flaps. Patients were stratified by takedown timing. Complication rates and flap characteristics were compared between early and conventional takedown groups. A total of 141 patients were included: 75 postauricular (52 early), 38 melolabial (23 early), and 28 paramedian forehead flaps (14 early). Across all flap types, complication rates (infection, dehiscence, necrosis) were low and did not differ significantly between early and conventional takedown groups. Flap and defect sizes were comparable. Early takedown of postauricular, melolabial, and paramedian forehead interpolation flaps at 2 weeks is safe and not associated with increased complications or poor surgical outcome.

Many reconstruction methods have been introduced for the reconstruction of basal cell carcinoma (BCC) post excision however no study has described the preferred reconstruction method in the Malaysia setting. Variations in resource availability and surgical training between regions may affect reconstructive choices. This study intends to find out our preferred method for reconstruction in nasal BCC patients post excision in our centre. We conducted a retrospective chart review of patients undergoing different reconstruction methods and assessing outcomes for a series of patients with BCC post-resection, conducted in Hospital Universiti Sains Malaysia (HUSM) and Hospital Raja Perempuan Zainab II, Kelantan, from 2012 to 2024. A total of seven patients were identified in this retrospective study, comprising five females and two males. The ages of these seven patients range from 60 to 77 years old. All seven patients who underwent excision postoperatively underwent immediate soft tissue reconstruction with either a local or regional flap, a free flap, or a combination of flaps. Among those seven patients, only one developed flap-related complications. All patients were followed up for at least 3 months, with a range of 3-38 months. Functional and cosmetic assessments over the resected area post-reconstruction were good. Local flaps remain the preferred option for small and medium nasal BCC defects, while forehead flaps and free flaps are reserved for larger or complex defects. In Asian patients, thicker skin and pigmentation influence flap design and thinning to optimize outcomes.