Donor Site Closure in Paramedian Forehead Flap Reconstruction: Impact on Scar Quality and Patient Satisfaction

Background: The paramedian forehead flap (PMFF) is a longstanding, versatile technique used in nasal reconstruction offering robust vascularity and excellent aesthetic outcomes. While the donor site is usually closed primarily, tension can make this challenging and may create widened scarring or dehiscence. Methods: A retrospective review of 108 patients undergoing PMFF following an excision of a basal or squamous cell carcinoma between January 2015 and December 2023 by a single surgeon was performed. Size of defect, location, postoperative complications, scar quality, and analysis using the validated Patient and Observer Scar Assessment Scale (POSAS) were used to assess patient satisfaction with their donor site scar. Results: The PMFF donor site was closed primarily in 50.9% of patients, with a skin graft in 16.7% and with a hemicoronal flap in 32.4%. Primary closure exhibited higher complication rates (wound dehiscence, alopecia) in medium defects (2–4 cm) and worse cosmesis (POSAS 40) compared with small defects <2 cm (POSAS 15). Skin grafting showed the worst cosmesis (POSAS 42) despite no complications. The hemicoronal flap group demonstrated the best cosmesis (POSAS 9 for medium defects and 14 for large (>4 cm) defects) and no complications, suggesting superior scar quality and minimal tension. Conclusion: The hemicoronal flap shows promise in decreasing wound tension and improving the scar quality in PMFF. This helps decrease complications associated with high wound tension as well as increase patient satisfaction in their scar.