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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_688_Библиотеки_им_академика_М_И_Перельмана
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6 Forehead Reconstruction
Upper Forehead
V-T ap: Medium and large defects. See medial defects (Figs.6.6a–d and 6.14).
Tips: In addition, the lateral ap is raised in the subcutaneous plane to avoid
damage to the frontal branch of the facial nerve.
Lateral Forehead/Temple (Between theLateral Orbital Rim
andZygomatic Arch)
Elliptical excision: Small defects can be converted into an ellipse, oriented to lie
parallel to the crow’s foot. The incisions and any undermining are best carried out
in the subcutaneous plane in an attempt to avoid damage to the temporal branch of
the facial nerves, which runs deep to the facial muscles.
V-T Flap
Indication: For defects that are triangular or can be converted into a triangle. The
“V-T” ap offers the advantage of utilising a vertical scar in crow’s foot and hiding
the horizontal scar inside the hairline.
Technique: The base of the triangle is fashioned to be towards the hairline, with
horizontal incisions extending laterally from the margins of the basal defect, inside
the hairline. The horizontal incisions and any undermining are best carried out in the
subcutaneous plane in an attempt to avoid damage to the temporal branch of the
facial nerve (Fig.6.14a–j).
Tips: Due to the difference in the lengths of the ap adjacent to the horizontal
incisions, Burrow’s triangles will have to be excised and are best positioned superiorly, within the hairline.
Lateral Forehead/Temple (Between theLateral Orbital Rim andZygomatic Arch)
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a
b
c
Fig. 6.14 V-T ap. (a) Markings for excision and ap, (b) Excision defect, aps raised and dog
eras excised, (c) Final closure, (d) Markings for excision and ap, (e) Excision defect, (f) Incisions
for ap, (g) Flaps raised and undermined, (h) Trial transposition, (i) Closure with delineation of
dog ears, (j) Final closure
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h
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6 Forehead Reconstruction
d
e
fg
j
Fig. 6.14 (continued)
Lateral Forehead/Temple (Between theLateral Orbital Rim andZygomatic Arch)
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Rotation/Transposition Flap
Indications: Medium defects. For defects that are triangular or can be converted
into a triangle, a rotation/transposition ap offers the advantage of utilising a vertical scar in crow’s foot and hiding the curvilinear scar inside the hairline.
Technique: The base of the triangle is fashioned to be towards the hairline, with
the curvilinear incision extending laterally from the margin of the basal defect,
inside the hairline, towards the pre-auricular skin crease. The tissue laxity in the
temporal/pre-auricular region is utilised to close the defect (Fig.6.15a–c).
Tips: 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, within the hairline.
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6 Forehead Reconstruction
a
b
c
Fig. 6.15 Rotation/transposition ap. (a) Markings for excision and ap, (b) Defect folllowing
excision and ap raised, (c) Final closure
Lateral Forehead/Temple (Between theLateral Orbital Rim andZygomatic Arch)
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Rhombic Flap (Limberg Flap)
Indications: Medium defects. For defects that are rhomboid or can be converted
into a rhombus, the Limberg ap offers the advantage of utilising the skin laxity
adjacent to the lateral canthus.
Technique: Technically, four aps can be raised for any given defect, and the
nal decision is based on tissue laxity and the orientation of the eventual scars. An
incision is made by extending the short diagonal by a length equal to one side of the
defect and a further incision is made from its extremity parallel to the adjacent side
of the defect, again of equal length. The incision and any undermining are best carried out in the subcutaneous plane in an attempt to avoid damage to the temporal
branch of the facial nerve. The wound is closed in layers (Fig.6.16a–h).
Tips: The amount of skin available in the adjacent area can be assessed using the
“pinch test.” With a rhomboid ap, some but not all the scars can be placed along
the skin creases. It is often easier to close the secondary defect rst followed by the
primary defect. In the case of circular defects, it is not always necessary to remove
additional tissue to convert the defect into a rhomboid.
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abc
6 Forehead Reconstruction
d
f
e
g
Fig. 6.16 Rhombic ap. (a) Markings for excision and ap, (b) Excision defect and aps raised,
(c) Final closure (d) Markings for excision and ap, (e) Excision defect and ap incisions, (f) ap
raised and undermining of margins, (g) closure of secondary defect, (h) Final closure
Lateral Forehead/Temple (Between theLateral Orbital Rim andZygomatic Arch)
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h
Fig. 6.16 (continued)
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6 Forehead Reconstruction
Unilateral/Bilateral Advancement Flaps
Indications: Small, medium defects.
Technique: The defect is ideally converted to have parallel sides. Parallel curvi-
linear incisions are made from the base of the defect and extend laterally and/or
medially, parallel to the frown lines. The incisions and any undermining are best
carried out in the subcutaneous plane in an attempt to avoid damage to the frontal
branch of the facial nerve. In the case of bilateral aps, one ap is initially raised
and assessed to see if it adequate, before the second ap is raised (Fig.6.17a–e).
Tips: Due to the difference in the lengths of the ap adjacent to the horizontal
incisions, Burrow’s triangles will have to be excised and are best positioned medially in the glabellar region or laterally in the crow’s foot region.
de
Lateral Forehead/Temple (Between theLateral Orbital Rim andZygomatic Arch)
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ab c
Fig. 6.17 Bilateral advancement aps. (a) Markings for excision and aps, (b) Excision defect
and aps raised, (c) Final closure, (d) Markings for excision and aps, (e) Final closure
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