Comparison of W-Plasty vs Traditional Straight-Line Techniques for Primary Paramedian Forehead Flap Donor Site Closure

IMPORTANCE: The paramedian forehead flap (PMFF) donor site scar is hard to disguise and may be a source of patient dissatisfaction. OBJECTIVE: To evaluate the aesthetic outcome of W-plasty vs traditional straight-line (SL) closure techniques of the PMFF donor site. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was conducted at the University of California, San Francisco Medical Center. Clinical history and operative reports were reviewed for 31 patients who underwent a PMFF procedure performed between November 1, 2011, and May 29, 2014. Blinded photographic analysis of postoperative photographs was performed. INTERVENTIONS: The pedicled component of the PMFF was raised primarily with either a W-plasty or traditional SL design. MAIN OUTCOMES AND MEASURES: Standard photographs of the donor site, obtained at least 90 days after surgery, were reviewed and scored in a blinded fashion by 4 dermatologic surgeons using a 100-point visual analog scale (from 0 worst possible outcome to 100 best possible outcome) and a 5-point Likert scale (from very poor to excellent). Interrater reliability was assessed via Cronbach α testing. RESULTS: All 31 forehead flaps survived during this study period; 16 PMFFs were raised with the W-plasty technique and 15 were raised with the SL technique. The W-plasty and SL groups were similar in terms of age, sex, and race/ethnicity (mean SD age, 68.4 12.4 vs 61.8 11.6 years; 13 84% vs 9 60% men; and 15 94% vs 13 87% white). Patients undergoing W-plasty closure had significantly higher mean visual analog scale scores compared with those undergoing SL closure (72.8 18.3 vs 65.6 18.1; P = .03). Mean Likert scale scores for W-plasty were higher than those for SL closure, but the difference was not significant (3.77 1.02 vs 3.43 0.98; P = .08). Overall interrater reliability for the visual analog scale and Likert scale scores were 0.67 and 0.58, respectively. CONCLUSIONS AND RELEVANCE: Patients undergoing PMFF donor site closure using a primary W-plasty technique demonstrated better mean scar appearance of the forehead donor site compared with SL closure. The primary W-plasty technique did not result in any PMFF losses and should be considered for appropriate patients. LEVEL OF EVIDENCE: 3.