“Assessing the Extent and Safety of Flap Re-Elevation in 2-Stage Paramedian Forehead Flap Revisions”

BACKGROUND: The paramedian forehead flap (PMFF) is the gold standard for reconstructing complex nasal defects. While 2-stage PMFFs commonly require revision, the extent to which they can be safely re-elevated after pedicle division remains unclear. Prior reports describe re-elevation up to 60% to 80%, but no studies have objectively quantified this. This study evaluates the safe extent of PMFF re-elevation using image-based measurements. METHODS: A retrospective review was conducted of patients who underwent 2-stage PMFF reconstruction and at least one revision between January 2020 and June 2025. Standardized photographs taken at division/inset and at revision were analyzed using ImageJ to measure preoperative and postoperative flap circumference. The percentage of flap re-elevation was calculated as the postoperative circumference divided by the preoperative circumference. Patient demographics, defect characteristics, biological adjunct use, and complications were recorded. Univariable and multivariable logistic regression assessed associations between flap elevation and postoperative complications. RESULTS: Thirty-nine patients were included (mean age 64.7±11.5 years; mean follow-up 14.3±12.3 mo). The mean flap elevation percentage at the first revision was 87.95%±9.27%. Nine patients underwent a second revision (mean elevation 83.06%±13.36%). The overall complication rate was 7.69%, including 2 infections and one partial flap necrosis; no total flap losses occurred. Flap elevation percentage was not associated with complications on univariable or multivariable analysis ( P >0.05). DISCUSSION: PMFFs can be safely re-elevated to nearly their full circumference following pedicle division. Extensive re-elevation does not increase complications and supports more aggressive contouring during revision to optimize nasal form and function.