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Original Investigation
March 14, 2019

Postoperative Complications of Paramedian Forehead Flap Reconstruction

Author Affiliations
  • 1Division of Facial Plastic and Reconstructive Surgery, Washington University School of Medicine, St Louis, Missouri
  • 2Division of Facial Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, California
  • 3Associate Editor, JAMA Facial Plastic Surgery
JAMA Facial Plast Surg. 2019;21(4):298-304. doi:10.1001/jamafacial.2018.1855
Key Points

Question  What are the rates of postoperative complications and hospital readmissions in patients receiving paramedian forehead flap surgery?

Findings  In this cohort study of data from 2175 patients, overall complication rates were low, including postoperative deep venous thrombosis. The most common complication was postoperative infection, while postoperative bleeding had the greatest odds of hospital readmission within the first 48 hours of surgery.

Meaning  Forehead flap surgery can be safely performed for patients with facial cancer in the outpatient setting without the need for anticoagulation; postoperative bleeding in this population carries the greatest risk for readmission.


Importance  Paramedian forehead flaps are commonly used to reconstruct facial defects caused by skin cancers. Data are lacking on the complications from this procedure, postoperative outcomes, and association of cancer diagnosis with rate of deep venous thrombosis (DVT).

Objectives  The primary objective was to determine complication rates after paramedian forehead flap reconstruction for defects resulting from resection of facial cancers; and the secondary objective was to determine patient factors and complications that are associated with readmission.

Design, Setting, and Participants  Retrospective cohort study of patients who underwent paramedian forehead flap reconstruction for skin cancer reconstruction from January 1, 2007, through December 31, 2013. Data analysis took place between October 1, 2017, and June 1, 2018.

Main Outcomes and Measures  Complication rates including DVT, emergency department visits, and hospital readmissions.

Results  A total of 2175 patient were included in this study; mean (SD) age, 70.3 (13.4) years; 1153 (53.5%) were men. Postoperative DVT occurred in 10 or fewer patients (≤0.5%); postoperative bleeding in 30 (1.4%), and postoperative infection in 63 (2.9%). Most patients went home on the day of surgery (89.6%; n = 1949), while 10.4% stayed one or more days in the hospital (n = 226). Overnight admission was associated with tobacco use (odds ratio [OR], 1.65; 95% CI, 1.11-2.44), hypothyroidism (OR, 1.93; 95% CI, 1.10-3.39), hypertension (OR, 1.82; 95% CI, 1.29-2.57), ear cartilage graft (OR, 2.20; 95% CI, 1.51-3.21), and adjacent tissue transfer (OR, 1.88; 95% CI, 1.33-2.67). Risk factors strongly associated with immediate return to the emergency department or readmission within 48 hours of surgery included postoperative bleeding (OR, 13.05; 95% CI, 4.24-40.16), neurologic disorder (OR, 4.11; 95% CI, 1.12-15.09), and alcohol use (OR, 7.70; 95% CI, 1.55-38.21).

Conclusions and Relevance  In this study, the most common complication of paramedian forehead flap reconstruction was infection. Risk factors for readmission included development of postoperative bleeding, having a neurologic disorder, and alcohol use. Deep venous thrombosis was a rare complication. Because bleeding is a more common complication in this patient population, discretion should be used when deciding to administer anticoagulation medication to low- to medium-risk patients prior to surgery.

Level of Evidence  NA.