INTRODUCTION
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).
Surgical technique
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.
DISCUSSION
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
