Outcomes of the Paramedian Forehead Flap for Nasal Reconstruction: Systematic Review and Meta-Analysis

Paramedian forehead flap (PMFF) reconstruction remains the gold standard for complex nasal defects, yet outcomes have not been comprehensively synthesized. We aimed to define flap survival, complication profiles, and reconstructive patterns through the largest systematic review and meta-analysis of PMFFs to date.

CINAHL, Cochrane Library, PubMed, and Scopus.

Databases were searched from inception through June 2026. Observational studies of PMFFs for nasal reconstruction were included; non-English, non-human studies, and case series with ≤ 5 participants were excluded. Continuous measures, proportions, and proportional differences (Δ%) were meta-analyzed with 95% confidence intervals (CI).

Across 69 studies (n = 4100), mean age was 59.3 years (95% CI: 54.6-64.0; range: 1-95), 54.3% were male, and mean follow-up was 19.8 months (95% CI: 15.2-24.3). Basal cell carcinoma was the most common indication (64.9%), followed by trauma (33.9%). Full-thickness defects comprised 55.3% of reconstructions. Two-stage reconstruction predominated (67.9%), followed by three-stage (18.7%) and single-stage approaches (5.6%). Complications were infrequent; scar retraction (6.6%), bleeding (6.2%), and venous congestion (6.1%) were most common. Flap survival did not differ by stage number, indication, or perforator localization. Venous congestion was more frequent after single-stage reconstruction (6.0%) versus two-stage (0.5%; Δ5.5%, 95% CI: 1.6%-15.1%; p < 0.0001) and three-stage procedures (1.2%; Δ4.9%, 95% CI: 0.6%-14.5%; p = 0.0146). Cartilage grafting reduced complete flap survival by 3.4% (95% CI: 0.04%-9.4%).

This largest-to-date meta-analysis demonstrates that PMFF provides consistently high reliability with low complication rates across indications and techniques, while identifying venous congestion differences that may inform surgical decision-making and counseling.