Ipsilateral vs. Contralateral Pedicle in Expanded Forehead Flap for Alar Necrosis: Which is Better?

OBJECTIVE: To investigate the outcomes of utilizing an expanded paramedian forehead flap combined with an autologous costal cartilage framework for reconstructing alar necrosis defects caused by hyaluronic acid injection, and to compare the clinical differences between ipsilateral and contralateral pedicle designs. METHODS: In this retrospective study (May 2021-August 2024), 21 patients underwent staged reconstruction: tissue expansion, flap transfer with cartilage framework based on ipsilateral (n=10) or contralateral (n=11) pedicles, followed by pedicle division and revision. Outcomes were assessed using ROE and NOSE scales and blinded photographic evaluation. RESULTS: All flaps survived completely. Postoperative ROE increased and NOSE decreased significantly (both P < 0.05). Between-group comparisons demonstrated negligible effect sizes with wide confidence intervals, and post hoc power for the primary outcome (ROE improvement) was only 9%. No statistically significant differences were observed, but the study was underpowered to detect equivalence. CONCLUSION: The expanded paramedian forehead flap combined with costal cartilage rhinoplasty is an effective strategy for reconstructing this type of iatrogenic alar defect. Our preliminary, underpowered comparison suggests that both pedicle designs can yield satisfactory outcomes; however, these findings do not establish equivalence, and pedicle choice should be individualized based on patient anatomy and biomechanical considerations. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .