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Aesthetic and Functional Outcomes of 2-Stage Versus 3-Stage Paramedian Forehead Flap Techniques: A 9-Year Comparative Study With Prospectively Collected Data

Stahl, Adelana S. MD*; Gubisch, Wolfgang MD, PhD*; Haack, Sebastian MD*; Meisner, Christoph ScD; Stahl, Stéphane MD

doi: 10.1097/DSS.0000000000000468
Original Article

BACKGROUND The 3-stage forehead flap technique has been described as an aesthetic improvement after nasal reconstruction compared with the 2-stage technique. A standardized evaluation of aesthetic and functional outcomes of the 2-stage versus 3-stage paramedian forehead flap after nasal reconstruction was performed.

METHODS Between July 2003 and December 2012, 102 patients underwent either 2-stage or 3-stage paramedian forehead flap techniques. A standardized patient satisfaction questionnaire was used to assess resulting nasal appearance and function. Additionally, 2 plastic surgeons performed blinded assessments of the aesthetic outcome using a standardized photographic evaluation form. Together, these evaluations demonstrated functional and aesthetic outcomes (flap thickness, shape, color, flap hair growth, donor-site scars, and nasal symmetry).

RESULTS Functional and aesthetic outcomes according to the self-assessment questionnaire were similar between groups. On inclusion of the surgeon's evaluation, with a greater satisfaction was apparent from the reconstructed alar of the 2-stage group (Mann–Whitney U test, p = .03, Fisher exact test, p = .024, respectively).

CONCLUSION No clear evidence supported enhanced aesthetic results when the 3-stage forehead flap technique was used, especially in relation to flap thickness compared with the 2-stage technique. The 2-stage technique remains the state-of-the-art choice for nasal reconstruction, even in cases involving complex defects.

LEVEL OF EVIDENCE Therapy, Level III, and retrospective comparative study with prospectively collected data.

*Department for Plastic Surgery, Marienhospital Stuttgart, Stuttgart, Germany;

Institute for Clinical Epidemiology and Applied Biometry, Eberhard-Karl University of Tübingen, Silcherstr, Tübingen, Germany;

Department of Plastic, Hand and Reconstructive Surgery and Burn Center of the BG-Trauma Center, Eberhard-Karl University, Schnarrenbergst, Tübingen, Germany

Address correspondence and reprint requests to: Adelana S. Stahl, MD, Department for Plastic Surgery, Marienhospital Stuttgart, Böheimstraße 37, 70199 Stuttgart, Germany, or e-mail:

The authors have indicated no significant interest with commercial supporters.

Statement of institutional review board approval: The study was conducted with the approval of the Ethics Review Board of Eberhard-Karl-University, Tuebingen, Germany (Approval Number 020/2011BO2).

© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.
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