Comparative analysis of two-stage versus three-stage paramedian forehead flap for nasal reconstruction: a systematic review and meta-analysis

Abstract Background The paramedian forehead flap remains the gold standard for complex nasal reconstruction. Traditionally performed in two stages, a three-stage modification has been proposed to improve vascular reliability and contouring. However, its relative benefit compared with the standard two-stage approach remains unclear. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of two-stage versus three-stage paramedian forehead flaps in nasal reconstruction. Methods Following PRISMA 2020 and Cochrane guidance, we systematically searched PubMed, Embase, Scopus, and Google Scholar through August 2025. Eligible studies compared two-stage (2 S) and three-stage (3 S) forehead flaps. Primary outcomes were infection, wound breakdown, and flap necrosis; secondary outcomes included revision surgery and patient satisfaction. Risk of bias was assessed with ROBINS-I and certainty of evidence with GRADE. Pooled risk ratios (RR) or standardized mean differences (SMD) were estimated using random-effects models. The protocol was registered in PROSPERO. Results Seven retrospective cohort studies including 428 patients (207 3 S, 221 2 S) met inclusion criteria. Meta-analysis demonstrated no significant differences between 3 S and 2 S techniques for infection (RR 1.55, 95% CI 0.50–4.83), wound breakdown (RR 1.20, 95% CI 0.41–3.52), flap necrosis (RR 1.25, 95% CI 0.52–3.02), or revision surgery (RR 1.28, 95% CI 0.67–2.43). Patient satisfaction did not differ significantly (SMD 0.38, 95% CI − 0.78 to 1.53), though heterogeneity was high ( I² = 81%). Egger’s test showed no publication bias for necrosis ( p = 0.823). GRADE certainty was low for all outcomes and very low for satisfaction. Conclusions Two- and three-stage forehead flaps yield comparable complication rates and patient-reported outcomes. Current evidence, limited to retrospective studies, does not demonstrate superiority of either approach. Surgical staging should be individualized based on defect complexity and patient risk, while prospective comparative studies are needed to strengthen the evidence base. Level of Evidence : not gradable.