Reconstruction of Full-Thickness Eyelid and Periorbital Defects Using the Paramedian Forehead Flap

Introduction: Reconstruction of subtotal full-thickness eyelid defects involving the canthi is challenging because successful repair must restore eyelid function, protect the ocular surface, and achieve acceptable periocular aesthetics. Although the paramedian forehead flap (PMFF) is well established for nasal reconstruction, its application in complex eyelid and periorbital defects is less commonly reported. The authors evaluated outcomes following PMFF reconstruction for subtotal full-thickness eyelid and periorbital defects. Methods: A retrospective review was performed of patients undergoing PMFF reconstruction for periorbital defects involving full-thickness eyelid loss and medial or lateral canthal involvement between 2013 and 2024. Cases were included when defects were not amenable to primary closure or standard local eyelid reconstruction. Patient demographics, pathology, defect characteristics, reconstructive techniques, complications, and functional outcomes were analyzed. Results: Twenty-six patients (mean age 76 y) underwent PMFF reconstruction. Pathology included basal cell carcinoma (n=18) and squamous cell carcinoma (n=8); 3 cases represented recurrence following prior radiotherapy. Defects involved the lateral canthus in 17 cases and the medial canthus in nine cases. Posterior lamellar reconstruction was most commonly performed using a transconjunctival flap, and lateral canthal support was reconstructed with a periosteal orbital flap in lateral canthal defects. In 4 medial canthal cases, the PMFF alone was used for full-thickness reconstruction with distal pericranium incorporated to recreate the conjunctival lining. Pedicle division was performed 4 to 8 weeks postoperatively. There were no flap losses and no postoperative infections or major complications were documented. All patients achieved clinically satisfactory eyelid closure without worsening ocular surface symptoms compared with baseline. Conclusion: PMFF is a reliable and versatile option for reconstruction of complex periorbital defects involving full-thickness eyelids and canthi. In this series, PMFF reconstruction demonstrated excellent flap survival, minimal morbidity, and consistently favorable functional outcomes, supporting its role as a valuable technique in select challenging periocular reconstructions.