Early Division of the Paramedian Forehead Flap: A Systematic Review and Retrospective Analysis.

Objective: To determine whether and when early division of the paramedian forehead flap may be safely performed.

Data Sources: PubMed (NLM), Scopus (Elsevier), and Embase (Elsevier).

Methods: A systematic search of PubMed, Scopus, and Embase was conducted according to PRISMA guidelines. Data extraction included time to pedicle division, patient and defect characteristics, and postoperative complications. Additionally, a retrospective analysis of patients at our institution was performed to augment the cohort.

Results: A total of 103 patients (85 from 6 studies identified via systematic review and 18 via retrospective review) underwent early flap division defined as 16 days and earlier. The average time to division was 9.89 days (3-16). There were no cases of flap loss, and complications were rare. Several studies excluded full thickness defects. Five studies included patients requiring cartilage grafting, although some limited this to less than 50% of the defect area. All patients in our retrospective cohort had partial thickness defects and none required cartilage grafting. Despite smoking being a major risk factor for vascular disease, 13.7% of patients were current smokers. Several studies utilized imaging tools such as indocyanine green angiography to assess flap perfusion. Notably, in these instances, no cases were delayed due to lack of adequate neovascularization.

Conclusion: Early paramedian forehead flap division may be an option in select patients with partial thickness nasal defects. Adjunct imaging may be a cost-effective method of evaluating appropriate timing of division.

Level Of Evidence: NA Laryngoscope, 2025.