The forehead flap in nasal reconstruction: overview and updates in evidence

Abstract

The paramedian forehead flap (PMFF) is an interpolated flap commonly used to reconstruct a variety of nasal defects. It is the preferred reconstructive method for moderate to large nasal defects, with advantages of robust blood supply, close color and texture matching with native nasal skin, relatively acceptable donor site morbidity, and ability to customize size and thickness. It may involve two or three stages to permit addition of cartilage grafts, debulking or other modifications, and pedicle division. Recent literature has supported numerous variations on the classically described forehead flap. These include shortened time to pedicle division, single-stage flaps, two-stage flaps for complex major reconstruction, pre-laminated flaps, and use of the forehead flap in total nasal reconstruction. Recent updates in the literature on PMFF in nasal reconstruction will be reviewed.

Keywords

Forehead flap / nasal reconstruction / plastic surgery

References

[1] Burget GC.Aesthetic restoration of the nose.Clin Plast Surg1985;12:463-80

[2] Park SS.Reconstruction of nasal defects larger than 1.5 centimeters in diameter.Laryngoscope2000;110:1241-50

[3] Correa BJ,Wolfswinkel EM.The forehead flap: the gold standard of nasal soft tissue reconstruction.Semin Plast Surg2013;27:96-103 PMCID:PMC3743909

[4] Menick FJ.Nasal reconstruction with a forehead flap.Clin Plast Surg2009;36:443-59

[5] Arianpour K.Nasal lining reconstruction with prelaminated forehead flap.Facial Plast Surg Clin North Am2024;32:239-46

[6] Aliotta RE,Vidimos A.Free vascularized fascia lata flap for total columella reconstruction.Am J Otolaryngol2022;43:103226

[7] Howard BE,Shockley WW.Total nasal reconstruction: advances in free tissue transfer for internal lining and structural support.Facial Plast Surg Clin North Am2024;32:247-59

[8] Menick FJ.Aesthetic refinements in use of forehead for nasal reconstruction: the paramedian forehead flap.Clin Plast Surg1990;17:607-22

[9] Conduto D,Pinto A,Pinheiro C.Healing by secondary intention or skin grafting for the paramedian forehead flap donor area.Cureus2025;17:e77076 PMCID:PMC11801314

[10] Little SC,Park SS.Complications with forehead flaps in nasal reconstruction.Laryngoscope2009;119:1093-9

[11] Ji J,Enin K.Factors associated with outcomes of facial reconstruction after mohs micrographic surgery.Craniomaxillofac Trauma Reconstr2024;17:NP131-7 PMCID:PMC11563020

[12] Chen CL,Branham GH.Postoperative complications of paramedian forehead flap reconstruction.JAMA Facial Plast Surg2019;21:298-304 PMCID:PMC6583852

[13] Wu SS,Oladeji T,Gastman B.Development of a risk prediction model for complications following forehead flaps for nasal and periorbital reconstruction.J Craniofac Surg2023;34:362-7

[14] DeSisto NG,Chowdhury N.Forehead flap practices: a cross-sectional survey of facial plastic and reconstructive surgeons.Facial Plast Surg Aesthet Med2024;26:256-61

[15] Menick FJ.A 10-year experience in nasal reconstruction with the three-stage forehead flap.Plast Reconstr Surg2002;109;1856-61

[16] Menick FJ.Practical details of nasal reconstruction.Plast Reconstr Surg2013;131:613e-30

[17] Stahl AS,Haack S,Stahl S.Aesthetic and functional outcomes of 2-stage versus 3-stage paramedian forehead flap techniques: a 9-year comparative study with prospectively collected data.Dermatol Surg2015;41:1137-48

[18] Palmer WJ,Kaki P.Outcomes and complications of 2-stage versus 3-stage paramedian forehead flaps.Otolaryngol Head Neck Surg2025;172:1888-96 PMCID:PMC12120034

[19] Santos Stahl A, Gubisch W, Fischer H, Haack S, Meisner C, Stahl S. A cohort study of paramedian forehead flap in 2 stages (87 flaps) and 3 stages (100 flaps).Ann Plast Surg2015;75:615-9

[20] Woodard CR.Intraoperative angiography using laser-assisted indocyanine green imaging to map perfusion of forehead flaps.Arch Facial Plast Surg2012;14:263-9

[21] Eskiizmir G,Ozgur E,Cengiz Ozyurt B.Hemodynamic changes in paramedian forehead flap.J Craniofac Surg2018;29:159-62

[22] Colwell AS.Near-infrared spectroscopy in autologous breast reconstruction.Clin Plast Surg2011;38:301-7

[23] de Weerd L, Mercer JB, Setså LB. Intraoperative dynamic infrared thermography and free-flap surgery.Ann Plast Surg2006;57:279-84

[24] Singer R,Franklin JD.Fluorescein test for prediction of flap viability during breast reconstructions.Plast Reconstr Surg1978;61:371-5

[25] Hölzle F,Nolte D.Free flap monitoring using simultaneous non-invasive laser Doppler flowmetry and tissue spectrophotometry.J Craniomaxillofac Surg2006;34:25-33

[26] Abdelwahab M,Most SP.Utility of indocyanine green angiography to identify clinical factors associated with perfusion of paramedian forehead flaps during nasal reconstruction surgery.JAMA Facial Plast Surg2019;21:206-12 PMCID:PMC6537837

[27] Calloway HE,Most SP.Cost-effectiveness of early division of the forehead flap pedicle.JAMA Facial Plast Surg2017;19:418-20 PMCID:PMC5710623

[28] Surowitz JB.Use of laser-assisted indocyanine green angiography for early division of the forehead flap pedicle.JAMA Facial Plast Surg2015;17:209-14

[29] Rudy SF,Kandathil CK.Paramedian forehead flap pedicle division after 7 days using laser-assisted indocyanine green angiography.J Plast Reconstr Aesthet Surg2021;74:116-22

[30] Somoano B,Gladstone HB.Accelerated takedown of the paramedian forehead flap at 1 week: indications, technique, and improving patient quality of life.J Am Acad Dermatol2011;65:97-105

[31] Hsu FY,Su YJ,Yen CI.A prospective study of psychological adjustment during and after forehead flap nasal reconstruction.J Craniomaxillofac Surg2024;52:692-6

[32] Park SS.The single-stage forehead flap in nasal reconstruction: an alternative with advantages.Arch Facial Plast Surg2002;4:32-6

[33] Park SS.Revisiting the single-stage forehead flap in nasal reconstruction.JAMA Facial Plast Surg2013;15:383-4

[34] Longino ES,Most SP.Comparing perfusion of single-stage and multi-staged paramedian forehead flaps using indocyanine green angiography.Facial Plast Surg Aesthet Med2025;27:357-60

[35] Burget GC.The subunit principle in nasal reconstruction.Plast Reconstr Surg1985;76:239-47

[36] Gassner H,Haubner F,Kuehnel T.Prelamination to reconstruct internal nasal lining.Facial Plast Surg2013;29:411-6

[37] Griffin GR,Moyer JS.Interpolated subcutaneous fat pedicle melolabial flap for large nasal lining defects.Laryngoscope2013;123:356-9 PMCID:PMC4894529

[38] Okland TS,Perrault D.The single-stage melolabial flap for internal lining of full thickness defects of the nasal ala.Am J Otolaryngol2023;44:103804

[39] Ziegler JP.Prelaminated paramedian forehead flap for subtotal nasal reconstruction using three-dimensional printing.BMJ Case Rep2021;14:e238146 PMCID:PMC7839864

[40] Correa T,Owen SR.Trifold flap for total/subtotal nasal reconstruction.Facial Plast Surg Aesthet Med2025;27:169-73