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6 Forehead Reconstruction
Forehead Rotation Flap
Indications: Medium and large defects that triangular on can be converted into a
triangle. A forehead rotation ap based on the contralateral anterior branch of the
supercial temporal artery, supra-orbital/supra-trochlear vessels can be utilised.
Technique: A curvilinear incision is made from the base of the triangular defect,
inside the hairline and extended to the contralateral pre-auricular skin crease. Care
must be taken to avoid damage to the anterior branch of the supercial temporal
vessels. The ap is raised in the sub-galeal plane to avoid damage to the vascular
supply and beneath the supercial layer of the deep temporal fascia to avoid damage
to the temporal branch of the facial nerve. The wound is closed in layers and a pressure dressing/drain utilised as appropriate (Fig.6.18a–c).
Tips: Due to the difference in the lengths of the wound margins adjacent to the
curvilinear incision, Burrow’s triangles often have to be excised and are best positioned superiorly/posteriorly, within the hairline. The placement of the incisions
should take into account any potential changes to the hairline. Any dog ear is the
supra-orbital area which is revised to lie within the glabellar frown lines. The revision is best undertaken at a later date, to avoid vascular compromise.
Lateral Forehead/Temple (Between theLateral Orbital Rim andZygomatic Arch)
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a
b
c
Fig. 6.18 Forehead rotation/transposition ap. (a) Excision defect and ap markings, (b) Flap
raised and rotated into defect, (c) Final closure
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6 Forehead Reconstruction
Cervical/Cheek Rotation Flap
Indications: Medium/Large defects.
Technique: The defect is converted into a triangle, with the base laterally. The
incision is made from the base of the defect, along the pre-auricular skin crease and
extended inferiorly along a neck skin crease. The ap is raised in the subcutaneous
plane, taking care to avoid damage to the facial nerve branches. The ap is mobilised into the defect and closed in layers (Fig.6.19a–h).
Tips: If a large ap is raised, additional “anchoring/suspension” sutures should
be placed from the deep surface of the ap to the periosteum overlying the zygoma/
zygomatic arch, to prevent ap decent and ectropion. The ap can be extended inferiorly into a neck skin crease (cervicofacial). The cervical extension can be placed
behind the lobule of the ear and close to the hairline to camouage the scars.
When extending into the neck, the plane of dissection is in the supraplatysmal
plane. If dissection is undertaken deep to the platysma, care should be taken to avoid
damage to the mandibular branch of the facial nerve.
The inltration of tumescent solution can aid dissection and hemostasis. Due to
the difference in the lengths of the ap adjacent to the curvilinear incision, Burrow’s
triangles will have to be excised and are best positioned superiorly/posteriorly,
within the hairline and behind the ear lobe. The dog ear is the lateral canthus which
is revised to lie within the crow’s feet. The revision can be undertaken at a later date,
to avoid vascular compromise.
bc
Lateral Forehead/Temple (Between theLateral Orbital Rim andZygomatic Arch)
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a
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de
f
gh
Fig. 6.19 Cervical/Cheek rotation ap. (a) Markings for excision and ap, (b) Excision defect
and ap raised, (c) Final closure, (d) Markings for excision and ap, (e) Excision defect and ap
incisions, (f) Flap raised, (g) Final closure, (h) Early post operative result
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6 Forehead Reconstruction
Multiple Transposition Flaps±Skin Grafts
Indications: Large forehead defects, avoiding skin graft at the primary defect.
Technique: Two overlapping transposition aps are raised from the superior
margin of the defect, based laterally. The aps are raised in the sub-galeal plane and
the more “superior” ap transposed into the primary forehead defect and the “inferior” ap placed into the defect created by the “superior” ap. Third and fourth aps
can be raised from the posterior scalp to try and close all the defects primarily (al
la- Orticochea ap) or the residual defect in the less aesthetically sensitive area of
the scalp closed with skin grafts. The dog ears created by the transposed aps are
not corrected initially and are left in situ to preserve the blood supply. The often
atten out spontaneously or can be corrected later (after 6weeks) (Fig.6.20a–i).
Tips: Meticulous planning is necessary to get the orientation of the aps correct
and trial movements with a piece of towel is helpful. Do not be tempted to correct
the dog ears at the initial stage. The position of the eyebrows and the dog ears can
be corrected as a second-stage procedure. Depending on the hairline of the patient,
hair is likely to be transferred to the forehead and would have to be addressed.
cd
Lateral Forehead/Temple (Between theLateral Orbital Rim andZygomatic Arch)
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a
b
Fig. 6.20 Multiple transposition aps. (a) Markings for excision - anterior view, (b) Markings for
excision - poster view, (c) Markings for excision - lateral view, (d) Excision deefect and ap incisions, (e) Flaps raised, (f) Posterior ap transposed into anterior defect, (g) Anterior ap transposed into posterior defect, (h) Final closure with skin grafting of tertiary defect, (i) Ealy post
operative result with dog ear in situ
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6 Forehead Reconstruction
e
g
h
f
i
Fig. 6.20 (continued)
Lateral Forehead/Temple (Between theLateral Orbital Rim andZygomatic Arch)
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Skin Graft
Indications: Medium and large defects can be reconstructed with a full or partial
thickness skin graft.
Technique: A suitable template is made of the defect, which is transferred to the
donar site to harvest the graft. The graft is sutured to the defect, with additional
“long” sutures that can be used for “tying” over the bolus. If possible, the graft can
be “quilted” to the base, to decrease the risk of haematoma and dead space. A nonadherent dressing is laid over the sutured graft, over which a cotton wool ball/
sponge soaked in proavin or a suitable antibiotic ointment is placed. The tie-over
bolus sutures are now used to hold the dressing in place. Alternatively the dressing
could be held in place with skin staples (Fig.6.21a–d).
Tips: The cosmetic outcome is acceptable in the upper and lateral forehead,
where it can be “hidden” by alterations to the hair style.
In addition, very large defects involving most of the forehead can be satisfacto-
rily reconstructed with a skin graft, provided care is taken to place the margins
along the eyebrows, bridge of nose and hairline. The “take” of the skin graft is signicantly improved, when placed on a well-vascularised bed. The “take” on exposed
bone can be improved by utilising Ingetra® or a pericranial transposition ap (see
Chap. 5—Figs. 5.13 and 5.14).
Tissue expansion: This can be considered for large forehead defects when
staged reconstruction is planned for closure of the primary or secondary defect. It
can also be considered, when adequate time and tissue are available to carry out the
required expansion, prior to excision of the index pathology.
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6 Forehead Reconstruction
a
b
c d
Fig. 6.21 Skin grafting. (a) Lesion temple, (b) Excision defect and skin graft harvest site, (c)
Graft sutured in place with tie over sutures. Donar site sutured, (d) Tie over bolus dressing
Suggested Algorithm
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Suggested Algorithm
Forehead
Central Defects
Small
1. Primary closure (vertical).
2. “M” excision (Superior)
3. “W” excision (Inferior)
Medium
Upper
1. V-T ap.
2. Unilateral/bilateral advancement ap.
Lower
1. A-T ap.
2. Unilateral/bilateral advancement ap.
Paramedian
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Small
1. Primary closure (Vertical/horizontal).
Medium
Upper
1. V-T ap.
2. Unilateral/bilateral advancement ap.
3. Rotation/transposition ap.
Lower
1. A-T, V-T ap.
2. Unilateral/bilateral advancement ap.
Temple/Lateral Forehead
Small
1. Primary closure (along crow’s feet).
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