A Comparison Between 2-Stage Versus 3-Stage Paramedian Forehead Flap Aesthetic Outcomes and Complications for Nasal Reconstruction: A Systematic Review and Meta-Analysis

BACKGROUND: The paramedian forehead flap (PFF) remains the gold standard for complex nasal reconstruction; however, controversy persists regarding the optimal number of surgical stages. The 3-stage technique utilizes vascular delay to promote angiogenesis and allows for intermediate contour refinement, but inherently increases operative burden and health care resource utilization. This systematic review aimed to compare flap survival and aesthetic outcomes between 2-stage and 3-stage PFF reconstruction. METHODS: A systematic search of MEDLINE, PubMed, EMBASE, and Web of Science (CRD420261296186) identified comparative studies reporting complications and aesthetic outcomes following 2-stage and 3-stage PFF repair. Results were pooled through pairwise meta-analysis and standardized mean differences (SMD) using Cohen's d model. RESULTS: Seven studies comprising 428 patients were included in the final analysis: 221 patients underwent 2-stage PFF reconstruction and 207 patients underwent 3-stage reconstruction. Aesthetic outcomes were assessed in 3 studies (n=88) using a standardized mean difference model due to scale heterogeneity, demonstrating no significant difference between groups (SMD=-0.42, 95% CI: -2.40 to 1.56). Flap necrosis was reported in 6 studies (n=397), with no significant difference observed between 2-stage and 3-stage cohorts (OR=1.82, 95% CI: 0.78 to 4.28). Overall, neither flap survival nor aesthetic satisfaction differed significantly between the 2 reconstruction approaches. CONCLUSIONS: This review demonstrates comparable flap survival and aesthetic outcomes between 2-stage and 3-stage reconstructions. Future prospective studies utilizing standardized outcome measures are needed to clarify whether specific patient characteristics or defect complexities favor one technique.