Low Median Forehead Flap for Nasal Reconstruction: An Effective Modification to the Paramedian Forehead Flap

Abstract

Background:

Patients undergoing nasal reconstruction with the paramedian forehead flap (PMFF) can lead to scalp hair transfer and brow distortion. To minimize this, we have adopted the low median forehead flap (LMFF).

Objectives:

To compare the hypothetical flap reach of the LMFF with the PMFF and measure flap viability and hair transfer amongst patients undergoing nasal reconstruction.

Materials and Methods:

A multi-institutional retrospective chart review of patients undergoing the LMFF collected demographics, flap viability, brow distortion, and hair transfer. Photograph measurements compared the hypothetic flap reach between an LMFF or PMFF design.

Results:

Eighty patients (mean age 65 ± 13 [SD] years, 56.3% female) met inclusion after LMFF for nasal defects, mostly from skin cancer resection (93.8%) involving the tip (67.1%) and ala (73.4%); with ≥3 involved subunits (63.8%). Transferred scalp hair (n = 1, 1.3%), and no flap compromise occurred. In photograph analysis, the LMFF showed an 11.6% increase in flap reach as compared to the PMFF (p < 0.0001). Intra-rater and inter-rater variances were nonsignificant.

Conclusions:

The LMFF is a viable modification to the PMFF for nasal reconstruction, especially in patients with short hairline and/or distal nasal tip/alar defects where increased flap reach and minimal hair transfer are desired.

Key Points

Questions: What is the increased reach of a flap that can be achieved with a low median forehead flap (LMFF) design when compared to the traditional paramedian forehead flap (PMFF), and can this approach reduce the amount of scalp hair that could be transferred from the end of the forehead flap to the nasal defect?

Findings: All forehead flaps were viable, demonstrated increased reach, and transferred minimal to no hair-bearing skin to the nasal tip.

Meaning: The LMFF is an alternative to the paramedian forehead flap for patients undergoing nasal reconstruction, especially those with low hairlines or more distal nasal defects that require increased pedicle length without compromising flap survival and outcome.

Introduction

Nasal reconstruction has been performed on the Indian subcontinent since 600 BC.¹ The first documented Indian midline forehead flap in the English literature was in 1793.^2–5 Since then, the forehead flap has evolved from a wide-based, midline flap to a narrow-based paramedian forehead flap (PMFF) centered over the supratrochlear artery.^6,7 Today, the PMFF is the gold standard flap for reconstruction of large nasal defects with exposed cartilage.^8,9 It provides an excellent color and texture match to the nasal skin and has an anatomically reliable and robust axial blood supply.⁷ The flap can be lengthened by incising through the medial brow and isolating the pedicle at the supraorbital rim or by extending the distal flap into the hair-bearing scalp.¹⁰ Consequently, this may result in brow distortion or transfer of scalp hair to the nose, diminishing the cosmetic outcome for an otherwise beautiful reconstruction. The incidence of scalp hair transfer in PMFF has been reported to be as high as 23%, and current solutions such as tissue expansion, laser hair removal, and electrolysis require additional procedures that are expensive and unavailable in large portions of the world.^10–12 To circumvent scalp hair transfer and brow distortion, an alternate solution is needed.

The vasculature of the forehead has been well described in cadaveric and angiography studies, which established the supratrochlear system as both anatomically reliable and the dominant system for central forehead perfusion.^7,13 However, these studies also found the existence of more medial arterial systems, namely the paracentral artery, a terminal branch of the angular artery, and the central artery, originating from the dorsal nasal artery.^14,15 The paracentral and central arteries are more anatomically variable compared to the supratrochlear artery, though are generally within a 13 mm-wide zone starting 2 mm lateral to midline. The arteries were only identified in less than 50% of cadaveric specimens.^14,15 Faris et al. tested the potential of the medially based forehead flaps by theoretically basing the pedicle from the paracentral artery and the central artery.¹¹ A Doppler was not used to identify the paracentral and central arteries. There was no incidence of flap compromise, and there was a significantly decreased rate of scalp hair transfer with the central artery flap compared to the classical paramedian flap.¹¹ A separate case series of 20 patients who underwent a more medially based forehead flap for nasal reconstruction also reported robust flap survival despite not identifying an axial vessel.¹⁶ These studies, along with the ancient history of the flap, lead one to believe that capture of an identifiable axial artery is not required for forehead flap perfusion. This is further supported when considering that half of patients lack discretely identifiable paracentral and central arteries.

Alternatives to avoid scalp hair transfer in the forehead flap include tissue expansion of the forehead, oblique orientation up the forehead, laser hair removal, and various depilation staged surgeries.^17–19 The original Indian forehead flap, based midline and without an axial pedicle, presumptively achieved satisfactory results, having survived the test of time.^{6,11,16,20–22} The authors (D.A.S., T.T.T.) have therefore adopted the LMFF for the majority of nasal reconstructions, particularly in patients with low hairlines, nasal tip and ala defects, and defects requiring increased flap reach.

In this study, the objective is to compare theoretical reach in distance amongst patients undergoing nasal reconstruction with the LMFF compared to the traditional PMFF, as measured by distance estimates on photographs. We hypothesize that this case series and measurement study will provide data on the extended reach of the LMFF and along with future studies, will help inform a set of indications and contraindications of the LMFF.

Methods

A retrospective chart review was performed on all patients with nasal defects who underwent reconstruction with an LMFF between January 2018 and December 2024 by the senior authors (D.A.S., T.T.T.) at two tertiary care hospitals. After IRB approval at both institutions, data collection included patient demographics, medical comorbidities, and the etiology and extent of their nasal defect. The primary outcome was flap survival, as measured by any flap demargination or flap failure noted by primary surgeons in follow-up chart review. Secondary outcomes included the presence of scalp hair transfer on the flap to the nose, brow distortion, and need for revision procedures.

Surgical technique

Design of the forehead flap begins with an assessment of the forehead height (e.g., the potential forehead flap pedicle’s length), which is measured from the trichion to the medial eyebrow clubhead and is noted to occur in a range from approximately 4 to 8.5 cm. A traditional PMFF is depicted in Figure 1a, showing a 6.5 cm forehead height, which limits the reach of the flap to a distal nasal defect.

Fig. 1.

(a) Illustration of traditional paramedian forehead flap (PMFF) based off of the supratrochlear artery. The forehead height is measured from the hairline (trichion) to medial eyebrow clubhead and ranges from approximately 4 to 8.5 cm). A forehead flap in a patient with a short forehead is difficult to reach a columellar, alar, or distal nasal tip defect without transferring significant scalp hair. Therefore, the low median forehead flap is an alternative in these cases where a short forehead and distal nasal defect are present. (b) Illustration of the designed low median forehead flap (LMFF) with an inferiorly shifted base and more central donor site.

In comparison, the LMFF pedicle (Fig. 1b) is designed to be based with a medial vertical incision roughly at the midline, extending from the midline glabella to the hairline. The base of the pedicle can extend inferiorly from the midline glabella, passing inferiorly on the lateral nasal sidewall to create the necessary flap reach, as it is interpolated into the defect. (see Supplementary Video) The flap pedicle base is at the midpoint between the inferior eyebrow and medial canthus, just inferior to the nasion, within the lateral nasal wall region. This is medial and inferior to the supratrochlear neurovascular bundle in the PMFF’s pedicle. Preoperative Doppler was not performed for any vessel identification. The width of the pedicle tends to be between 1.0 and 1.8 cm by design, to allow rotation without kinking. (Note: when possible, the glabellar scarring may be camouflaged by placing the medial flap pedicle incision into the natural relaxed skin tension lines created by the corrugator muscles in the glabella furrow, which may be slightly off the midline).

After verifying the size of the flap using a foil template of the nasal defect, the flap is elevated in a subgaleal plane for the upper two-thirds of the flap and a sub-pericranial plane for the lower one-third, capturing additional perfusion from the deeper vasculature. The flap is selectively thinned in accordance with the recipient defect, then rotated and inset into the nasal defect in the standard fashion. As with a PMFF, the LMFF is usually a two-stage procedure with division and inset of the pedicle approximately 3 weeks after the initial stage. Division is moved up for patients with tissue-only defects and delayed for patients with significant underlying cartilage grafting, peripheral vascular disease, or other comorbidities that can delay flap revascularization. Occasionally, a three-stage approach is used to contour the flap, as popularized by Burget and Menick, in which the flap is elevated, thinned, and contoured, and any additional structural cartilage grafting is placed in an intermediate stage.²³ This is beneficial, especially when the first-stage internal lining reconstruction is not felt to be absolutely watertight, and avoids cartilage resorption issues.

Photograph analysis

Standardized frontal postoperative photographs of patients who underwent nasal reconstruction with the LMFF were taken uniformly with a digital single-lens reflex camera (Nikon D70; Nikon Corp, Tokyo, Japan, or Canon EOS 650 D; Canon Inc. Tokyo, Japan). The photographs were in frontal view with the irises and the hairline fully visible after the forehead flap division.

Measurements were performed using ImageJ Version 1.54 g (National Institutes of Health, USA). Measurements were scaled to an iris diameter of 11.5 mm.²⁴ Flap length was determined by the distance from the pivot point, or base of the flap, to the hairline directly vertical to the pivot point. For the PMFF, the pivot point was identified at the superior aspect of the medial brow, approximating the location of the supratrochlear artery. For the LMFF, the paracentral pivot point was identified at the midpoint between the inferior brow and the medial canthus, within the nasal sidewall. The distal point of the theoretical defect was defined as the distal nasal tip at the midline, which determined the required reach of the flap. Figure 2 illustrates the measurements made on the same patient photo for a PMFF (A) and an LMFF (B). The flap reach is calculated as the ratio between the flap length (A-B) and the distance between the pivot point to the distal nasal tip (A-C.) A flap reach of greater than or equal to 1 would indicate that the flap would not need to be cut or extended into the hairline in order to have the length to reach a distal nasal tip defect and therefore, not result in scalp hair transfer to the nose.

Fig. 2.

Photographic measurements for (a) the paramedian forehead flap and (b) the low forehead flap. Point A is the pivot point for the PMFF and point A’ is the pivot point for the LMFF, located at the nasal sidewall halfway between the inferior brow and the medial canthus.

Data collection and statistical analysis

Patient data were collected from the electronic medical record from both Massachusetts Eye and Ear (MEEI) and the University of California Davis (UC, Davis). To establish validity of using measurements collected by two people (R.H.L. and J.N.S.), inter-rater variance was calculated using Student’s t-test from independent measurements of the MEEI photo cohort by R.H.L. and J.N.S. Data normality was evaluated using the Shapiro-Wilk test, and normally distributed data are reported as means with standard deviations. Statistical analysis was performed using Student’s t-test on Stata/BE 17.0 (StataCorp, College Station, TX). Statistical significance was defined by p < 0.05.

Results

Eighty patients were included in the study, with 49/80 (61.3%) patients meeting inclusion criteria for the photograph analysis. The patients were nearly evenly distributed with regard to sex (56.3% female, n = 45) with a mean age of 65 (SD13) and median age of 67 (range: 23–87). Patient demographic information and relevant comorbidities are displayed in Table 1.

Table 1.

Patient characteristics and comorbidities

Age (years)
Mean (SD)	65 (13)
Median (Range)	67 (23–87)
Sex (N, %)
Female	45 (56.3%)
Male	35 (43.7%)
Etiology of nasal defect
Skin cancer resection	75 (93.8%)
Traumatic injury	3 (3.8%)
Other	2 (2.5%)
Medical comorbidities
Diabetes mellitus	9 (11.3%)
Tobacco Use (active)	7 (8.8%)
Peripheral vascular disease	2 (2.5%)
Chronic kidney disease	3 (3.8%)
Prior reconstruction^a	6 (7.5%)
Prior radiation therapy	1 (1.3%)

Includes local reconstruction, contralateral paramedian forehead flap, and radial forearm free flap.

Most nasal defects resulted from cutaneous skin cancer resection (93.8%, n = 75), with a minority from traumatic defects (3.8%, n = 3) and more rare neoplasms such as angiosarcoma and spindle cell neoplasm (2.5%, n = 2). Defects ranged in size from 1 to 30 cm² and involved anywhere from 1 subunit to all 9 nasal subunits in a total rhinectomy defect. The distribution of defects involved included: 1 subunit (n = 10, 12.5%), 2 subunits (n = 18, 22.5%), ≥ 3 subunits (n = 51, 63.8%), and 1 patient whose specific subunit involvement was unclear. The most common subunits (or combination of those) reconstructed were the nasal ala (n = 58, 73.4%), nasal sidewall (n = 54, 68.4%), and tip (n = 53, 67.1%), representing the most distal subunits from the pedicle base. (Fig. 4) Further breakdown of nasal subunit involvement can be referenced in Table 2. Representative patient examples are shown in Figures 3–5.

Table 2.

Individual nasal subunits involved the nasal defects

Nasal subunit	Number of total defects n = 80, %^a
Ala	58 (73.4%)
Sidewall	54 (68.4%)
Tip	53 (67.1%)
Dorsum	44 (55.7%)
Columella	44 (55.7%)
Soft Tissue Triangle	32 (40.5%)

Defects can involve 1- >3 subunits therefore the reported subunits involved will be reported individually and not sum up to 80 patients.

Fig. 3.

(a) Traumatic through and through defect of the right nasal ala in a patient with a low hairline. (b) Intraoperative image during first stage nasal reconstruction with an ipsilateral septal mucosal flap for nasal lining, auricular cartilage grafting (pictured), and eventual completion of the entire nasal tip subunit (not pictured), followed by design of a low median forehead flap (LMFF). With the low pivot point no hair is transferred to the nasal tip and the brow is not disrupted. (c) 3 weeks after LMFF, just prior to flap division and inset. (d) Four-year follow-up with symmetric brow, no hair on the reconstructed nose, and an acceptable result.

Fig. 4.

(a) A patient after staged excision of a nasal tip lesion, with a defect of the nasal tip, nasal dorsum and ala. (b) Intraoperative image after completion of the nasal tip subunit and design of the low median forehead flap (LMFF). (c) 2.5 weeks after LMFF, at which time flap division was performed. A low pivot point spares the brow and avoids hair transfer. (d) Postoperative image 2.5 years after flap division and debulking of flap, showing a symmetric brow and no hair on the nasal tip.

Fig. 5.

(a) Patient with nasal tip defect, (b) Defect converted to tip subunit and Low Median Forehead Flap designed to reduce scalp hair transfer, (c) 3 weeks postoperative, presenting for division and inset, Postoperative outcome at 1 year (d) Frontal view, (e) oblique view, (f) profile view (*note forehead height in this patient is closer to 7.5 cm showing the range of forehead height and distal nasal defects that the LMFF can be effective).

The mean length of follow-up was 24.8 (SD 25.2) months with the minimal follow-up of 1.4 months. No flap necrosis or failures occurred. To date, 22.5% (n = 18) of patients have undergone secondary debulking procedures for aesthetic subunit improvement. Three patients developed alar retraction (n = 3, 3.8%). There was one incidence of scalp hair transfer (n = 1, 1.3%) in reconstructing a total rhinectomy defect. No documented brow distortion was identified by photo reviewers; however, imaging software was not employed. (Fig. 5)

Photographic analysis was performed on all patients with complete photograph documentation (n = 49, 61.3%). A theoretical conventional PMFF was designed as well and compared to the LMFF, which resulted in a mean increase in flap length of 7.2 mm (SD: 13.0 mm), which translates to an 11.6% increase in reach. The distance from the LMFF pivot point, or flap base, to the distal nasal tip was a mean of 7.8 mm (SD: 4.3 mm), or 12.4%, shorter compared to that for the PMFF. Accordingly, the LMFF had a significantly higher ratio of flap reach at 1.4 (SD: 0.2) compared to 1.1 (SD: 0.2) for the PMFF (p < 0.0001). Additional photographic measurements for the PMFF and LMFF are shown in Table 3. Of note, the intra-rater variances were 0.98 and 0.77, while the inter-rater variance was 0.83 for flap reach.

Table 3.

Theoretical forehead flap reach for the paramedian forehead flap compared to the median low forehead flap, by measurement on photographs

Measurement	Paramedian forehead flap	Low forehead flap	p value
Mean flap length from pivot point to hairline (mm, SD)	64.8 (12.4)	72.0 (13.0)	<0.0001
Mean distance from pivot point to nasal tip (mm, SD)	61.4 (13.5)	53.6 (11.2)	0.0001
Ratio of forehead flap reach (SD)^a	1.1 (0.2)	1.4 (0.2)	<0.0001

The ratio of forehead flap reach is calculated by the distance from pivot point to hairline divided by distance from pivot point to the distal nasal tip.

Discussion

Our study seeks to look at the applicability and outcomes of the LMFF. The LMFF utilized in the current study shares similarities with the central artery forehead flap referenced by Faris et al. and the median forehead flap described by Skaria.^11,16 Unlike the Faris et al. study, the location of the skin paddle in this study was not always based in the anatomical center of the forehead.¹¹ Rather, the skin paddle location and orientation were tailored to account for considerations including the shape of the hairline, hairstyle, prior surgery, existing forehead scars, and required flap length. This demonstrates the adaptability of the LMFF, which mirrors the strengths of the PMFF.

The LMFF is a reliable flap for nasal reconstruction, with no cases of flap compromise in our series. While we can assume half of our LMFFs may have been perfused by an axial vessel such as the paracentral or central artery, we presume there were a significant number supplied by random pattern vessels of the central forehead. This finding suggests there may be increased versatility of the base location and skin paddle design of more medially based forehead flaps compared to the traditional PMFF. As in PMFFs, unfavorable aesthetic outcomes such as flap bulkiness, scarring, and alar retraction did occur in LMFFs, but these were addressed in subsequent minor revision procedures that are often expected in nasal reconstruction.

Due to the inability to perform both the PMFF and LMFF on the same patient, we relied on photographic analysis and used theoretical designs of both flaps to compare flap reach. Intuitively, shifting the flap base inferomedially from the supratrochlear vessel to the nasal side resulted in increased flap length while simultaneously decreasing distance to the nasal defect. Compared to the PMFF, the LMFF flap had an increased flap length of approximately 7 mm and an increased flap reach of 14 mm. This is within the range of 10–15 mm gain reported previously by Skaria for the medially based forehead flap, which shares a similar pivot point to the LMFF when compared to the PMFF.¹⁶ Applied clinically, the increased flap length and reach resulted in only minimal transfer of scalp hair and minimal brow distortion with no evidence of flap compromise.^11,16

We caution the use of LMFF in patients with significant vascular comorbidities such as active smoking, poorly controlled diabetes, and peripheral vascular disease. Other instances in which the PMFF may be preferred include those with through-and-through nasal defects when an underlying bed of healthy tissue at the recipient site is absent and those with higher Norwood classifications, whereby there is little to no risk of hair transfer with either flap. Therefore, in patients with severe vasculopathy, prior radiation, defects approaching the LMFF pedicle, or where an entire cartilage framework requires coverage, we sometimes rely on the PMFF and incorporate the supratrochlear vessels.

The current study is limited by the absence of a case control cohort of PMFF patients. Therefore, any comparisons between LMFF and PMFF are derived from photographic models and prior literature. Two-dimensional photographic models are limited in capturing three-dimensional patients. Specifically, the Z-axis, or the curvature of the forehead and the projection of the nasal tip, is not captured and can have impacts on flap reach. We defined the midline distal nasal tip as the farthest reach required on a frontal photograph but acknowledge that this may not represent the farthest reach clinically required if the columella is involved. Lastly, the photographic model cannot account for individual skin elasticity or laxity, which has a minimal impact on flap reach but can lead to clinical differences in wound tension and healing. We are engaged in future studies using indocyanine green angiography (SPY Elite System; LifeCell Corp Inc, Novadaq Technologies Inc)²⁵ to measure LMFF vascularity and directly compare PMFF and LMFF reach, hair transfer, and brow/nasal outcomes.

Conclusions

The LMFF design allows for increased flap reach while preventing hair transfer compared to the conventional PMFF. The LMFF provides an acceptable alternative to the PMFF without jeopardizing flap survival and should be considered in patients with low hairlines and distal nasal defects.

Authors’ Contributions

Project conceptualization: D.A.H. and T.T.T. Data curation, Methodology: D.A.S., R.H.L., J.S., M.K., and T.T.T. Writing of the original draft: D.A.S., R.H.L., J.S., M.K., and T.T.T. Resources: D.A.S. and T.T.T. Project Supervision: D.A.H. and T.T.T. Reviewing and editing of the article: D.A.S. and T.T.T.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was used for this study.

Supplemental Material

References

Shaye

. The history of nasal reconstruction. Curr Opin Otolaryngol Head Neck Surg. 2021; 29(4):259–264.

Angobaldo

, Marks

. Refinements in nasal reconstruction: The cross-paramedian forehead flap. Plast Reconstr Surg. 2009; 123(1):87–93.

Eisenberg

. A history of rhinoplasty. S Afr Med J. 1982; 62(9):286–292.

Furlan

, Mazzola

. Alessandro Benedetti, a fifteenth century anatomist and surgeon: His role in the history of nasal reconstruction. Plast Reconstr Surg. 1995; 96(3):739–743.

Shokri

, Kadakia

, Saman

, et al. The paramedian forehead flap for nasal reconstruction: From antiquity to present. J Craniofac Surg. 2019; 30(2):330–333.

Kazanjian

. The repair of nasal defects with the median forehead flap; primary closure of forehead wound. Surg Gynecol Obstet. 1946; 83:37–49.

Shumrick

, Smith

. The anatomic basis for the design of forehead flaps in nasal reconstruction. Arch Otolaryngol Head Neck Surg. 1992; 118(4):373–379.

Burget

, Walton

. Optimal use of microvascular free flaps, cartilage grafts, and a paramedian forehead flap for aesthetic reconstruction of the nose and adjacent facial units. Plast Reconstr Surg. 2007; 120(5):1171–1207.

Menick

. Aesthetic refinements in use of forehead for nasal reconstruction: The paramedian forehead flap. Clin Plast Surg. 1990; 17(4):607–622.

10.

Ding

, Huang

, Sun

, et al. Combination of extended paramedian forehead flap and laser hair removal in the reconstruction of distal nasal defect. Ann Plast Surg. 2021; 86(3 (Suppl 2)):S293–S298.

11.

Faris

, van der Eerden

, Vuyk

. The midline central artery forehead flap: A valid alternative to supratrochlear-based forehead flaps. JAMA Facial Plast Surg. 2015; 17(1):16–22.

12.

Yen

, Chang

, et al. Laser hair removal following forehead flap for nasal reconstruction. Lasers Med Sci. 2020; 35(7):1549–1554.

13.

Kelly

, Yavuzer

, Keskin

, et al. Functional anastomotic relationship between the supratrochlear and facial arteries: An anatomical study. Plast Reconstr Surg. 2008; 121(2):458–465.

14.

Kleintjes

. Forehead anatomy: Arterial variations and venous link of the midline forehead flap. J Plast Reconstr Aesthet Surg. 2007; 60(6):593–606.

15.

Koziej

, Polak

, Hołda

, et al. The arteries of the central forehead: Implications for facial plastic surgery. Aesthet Surg J. 2020; 40(10):1043–1050.

16.

Skaria

. Median forehead flap: A reliable alternative for nose repair. Dermatol Surg. 2015; 41(7):859–862.

17.

DeSisto

, Arnaud

, Chowdhury

, et al. Forehead flap practices: A cross-sectional survey of facial plastic and reconstructive surgeons. Facial Plast Surg Aesthet Med. 2024; 26(3):256–261.

18.

Han

, Zhou

, Yu

, et al. Optimal timing of laser hair removal in expanded forehead flap in the reconstruction of facial defects: During or after tissue expansion? Facial Plast Surg Aesthet Med. 2023; 25(6):466–471.

19.

Rudolph

, Walker

, Rebowe

, et al. Broadening applications and insights into the cross-paramedian forehead flap over a 19-year period. J Plast Reconstr Aesthet Surg. 2019; 72(5):763–770.

20.

Choi

, Bae

, Nam

, et al. Evaluation of the donor site after the median forehead flap. Arch Plast Surg. 2018; 45(3):259–265.

21.

Skaria

. The median forehead flap reviewed: A histologic study on vascular anatomy. Eur Arch Otorhinolaryngol. 2015; 272(5):1231–1237.

22.

Figi

, Moorman

WL.

Jr ., The median forehead flap–indications and limitations. Plast Reconstr Surg Transplant Bull. 1959; 24:163–174.

23.

Menick

. A 10-year experience in nasal reconstruction with the three-stage forehead flap. Plast Reconstr Surg. 2002; 109(6):1839–1855; discussion 1856–1861.

24.

Spörri

, Simmen

, Briner

, et al. Objective assessment of tip projection and the nasolabial angle in rhinoplasty. Arch Facial Plast Surg. 2004; 6(5):295–298; discussion 299–300.

25.

Longino

, Kandathil

, Most

. Comparing perfusion of single-stage and multi-staged paramedian forehead flaps using indocyanine green angiography. Facial Plast Surg Aesthet Med. 2025; 27(4):357–360; doi: 10.1089/fpsam.2024.0313

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