title: A Cohort Study of Paramedian Forehead Flap in 2 Stages (87 Flaps) and 3 Stages (100 Flaps).
abstract: BACKGROUND
  In nasal reconstruction, the paramedian forehead flap is traditionally performed in 2 stages. To minimize the risk of flap necrosis, Millard described a 3-stage technique in a series of 5 cases in 1974. In this technique, an intermediate step of flap thinning is performed after flap transfer and before pedicle division. In this article, we compare the 2- and 3-stage techniques of paramedian forehead flaps for nasal reconstruction to determine the type and prevalence of complications related to each procedure.
  
  
  METHODS
  Here, we present a retrospective review of a prospectively maintained database of paramedian forehead flaps for nasal reconstruction performed during a period of 6 years. We included all patients with 2- (n=87) and 3-stage (n=100) paramedian forehead flaps who had consistent and complete electronic patient records and followed them up for at least 6 months after pedicle division. We performed a regression analysis to adjust for the unequal distribution of complex cases.
  
  
  RESULTS
  Demographic factors and the causes for the nasal defects were similar in both groups. Although the nasal reconstructions were significantly more complex in the 3-stage group, the rate of partial forehead flap necrosis was similar in both groups (2-stage, 3.4%; 3-stage, 5%; P=0.601). A regression analysis showed that the relative risk of partial flap necrosis in complex cases did not differ significantly between groups (relative risk, 0.80; P=0.705).
  
  
  CONCLUSIONS
  To our knowledge, our study is the largest series published to date and the first one to compare the prevalence of forehead flap necrosis in the 2- versus the 3-stage technique for paramedian forehead flaps. We found no evidence that the use of a 3-stage forehead flap lowers the prevalence of necrosis. Until larger multicenter studies or meta-analyses can be conducted, smaller yet well-conducted studies such as the present one provide critical data and represent an important contribution to the field. Future research should investigate whether the 3-stage technique produces better aesthetic results than the 2-stage technique.
authors.affiliation: From the *Department of Facial Plastic Surgery, Marienhospital Stuttgart, Stuttgart; †Department of Medical Biometry, and ‡Department of Plastic, Hand and Reconstructive Surgery, Burn Center, BG-Trauma Center, Eberhard-Karl University of Tübingen, Tübingen, Germany.
authors.forename: Adelana
authors.initials: A
authors.lastname: Santos Stahl
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Gubisch
authors.forename: Helmut
authors.initials: H
authors.lastname: Fischer
authors.forename: Sebastian
authors.initials: S
authors.lastname: Haack
authors.forename: Christoph
authors.initials: C
authors.lastname: Meisner
authors.forename: Stéphane
authors.initials: S
authors.lastname: Stahl
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005546:Forehead / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D012189:Retrospective Studies; D012225:Rhinoplasty / Q000379:methods*; D013524:Surgical Flaps; D055815:Young Adult