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Original Investigation |

Comparison of W-Plasty vs Traditional Straight-Line Techniques for Primary Paramedian Forehead Flap Donor Site Closure

Emmanuel J. Jáuregui, BA1; Neelima Tummala, MD1; Rahul Seth, MD2; Sarah Arron, MD3; Isaac Neuhaus, MD3; Siegrid Yu, MD3; Roy Grekin, MD3; P. Daniel Knott, MD2
[+] Author Affiliations
1Medical student, Department of Otolaryngology–Head and Neck Surgery, School of Medicine, University of California, San Francisco
2Section of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, University of California, San Francisco Medical Center
3Department of Dermatology, School of Medicine, University of California, San Francisco
JAMA Facial Plast Surg. 2016;18(4):258-262. doi:10.1001/jamafacial.2016.0099.
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Importance  The paramedian forehead flap (PMFF) donor site scar is hard to disguise and may be a source of patient dissatisfaction.

Objective  To evaluate the aesthetic outcome of W-plasty vs traditional straight-line (SL) closure techniques of the PMFF donor site.

Design, Setting, and Participants  A retrospective cohort study was conducted at the University of California, San Francisco Medical Center. Clinical history and operative reports were reviewed for 31 patients who underwent a PMFF procedure performed between November 1, 2011, and May 29, 2014. Blinded photographic analysis of postoperative photographs was performed.

Interventions  The pedicled component of the PMFF was raised primarily with either a W-plasty or traditional SL design.

Main Outcomes and Measures  Standard photographs of the donor site, obtained at least 90 days after surgery, were reviewed and scored in a blinded fashion by 4 dermatologic surgeons using a 100-point visual analog scale (from 0 [worst possible outcome] to 100 [best possible outcome]) and a 5-point Likert scale (from very poor to excellent). Interrater reliability was assessed via Cronbach α testing.

Results  All 31 forehead flaps survived during this study period; 16 PMFFs were raised with the W-plasty technique and 15 were raised with the SL technique. The W-plasty and SL groups were similar in terms of age, sex, and race/ethnicity (mean [SD] age, 68.4 [12.4] vs 61.8 [11.6] years; 13 [84%] vs 9 [60%] men; and 15 [94%] vs 13 [87%] white). Patients undergoing W-plasty closure had significantly higher mean visual analog scale scores compared with those undergoing SL closure (72.8 [18.3] vs 65.6 [18.1]; P = .03). Mean Likert scale scores for W-plasty were higher than those for SL closure, but the difference was not significant (3.77 [1.02] vs 3.43 [0.98]; P = .08). Overall interrater reliability for the visual analog scale and Likert scale scores were 0.67 and 0.58, respectively.

Conclusions and Relevance  Patients undergoing PMFF donor site closure using a primary W-plasty technique demonstrated better mean scar appearance of the forehead donor site compared with SL closure. The primary W-plasty technique did not result in any PMFF losses and should be considered for appropriate patients.

Level of Evidence  3.

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Four Representative Intraoperative Photographs of W-Plasty Paramedian Forehead Flap Creation

A, Marking of natural forehead rhytids, pedicle position, and 5-mm horizontal lines. B, W-plasty design of cutaneous forehead flap pedicle. C, Closure of W-plasty design with interdigitation of the limbs. D, Nasal defect closed with forehead flap with W-plasty pedicle design.

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