Complex Forehead Defects: A Novel Reconstructive Technique and Review of Available Methods
June 2012 | Volume 11 | Issue 6 | Original Article | 759 | Copyright © 2012
Complex forehead defects may result from excision of tumors or trauma. The reconstructive challenge is determined by the extent of tissue loss, the quality of the remaining tissue, possibly comprised vascular supply to the affected region, and special considerations (eg, exposed bone or injury to underlying structures). This paper describes a novel reconstructive approach to correct a complex forehead defect with exposed bone and discusses the armamentarium of reconstructive options for such cases.
J Drugs Dermatol. 2012;11(6):759-761.
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A male, aged 76 years, presented with recurrent basal cell carcinoma (BCC) of the forehead, six years after simple excision of the primary lesion. Histopathological examination of the primary specimen verified that all surgical margins were free of the tumor. Upon presentation, the lesion was approximately 3 cm in diameter, located on the left temple, with a scar-like appearance with ill-defined borders. The patient underwent Mohs micrographic surgery (MMS) that required 7 layers to achieve complete extirpation of the tumor. Histopathological investigation revealed Morphea type BCC that had penetrated down to the plane of the periosteum, where it had spread medially along the frontal bone. The postoperative defect measured about 5.5 cm in diameter and consisted of soft tissue and exposed bone in the medial aspect (Figure 1).
Reconstruction took place under local anesthesia with Bupivocaine Adrenaline 0.5% and minimal IV sedation with Midazolam.1 A transverse incision was planned in the hairbearing area, extending from the supero-medial point of the defect to the right temporal region (Figure 2). The intact forehead was raised as a single flap at the sub-muscular plane and folded anteriorly to expose the galea aponeurotica (Figure 3). The transverse incision was deepened down to the bone and curved inferiorly at the right lateral side as much as possible to facilitate easy mobilization. A periosteal elevator was used to free the galea-periosteum flap from the underlying frontal bone. After mobilization, the flap was rotated laterally to the left side in order to cover the exposed bone and was secured to the temporal fascia with 6/0 Vicryl sutures (Figure 4). The hinged forehead was restored back in place to cover the exposed bone donor site (Figure 5) and the remaining defect, now providing a satisfactory recipient bed, was covered with a split thickness skin graft (STSG) harvested from the patient's thigh (Figure 6). The postoperative period was uneventful and full take of the graft was observed, indicating that the rotated galea-periosteum flap provided excellent blood supply to the overlying graft (Figure 7). The patient was pleased with the final result.
Exposed bone lacks the desired characteristics of well-vascularized recipient bed, therefore it cannot be directly covered with a skin graft. When challenged by a large forehead defect with exposed bone the reconstructive surgeon may choose from several reconstructive options, based on local or distant tissue.
There is a large repertoire of compatible free flaps, ranging from the latissimus dorsi to the radial forearm flap, depending on the defect size. In such cases the vascular pedicle is commonly anastomosed to the temporal artery (Visible in Figure 1). This type of procedure is carried out under general anesthesia by a specialized microsurgical team and takes several hours, after which the patient is hospitalized for about 1 week. Other disadvantages are increased donor site morbidity, a large visible scar, risk for anastomosis malfunction (ischemia or thrombosis) leading to partial or complete flap failure, compromised aesthetic result in terms of contour and color mismatch, and systemic or distant complications related to the extensive procedure.2-4