Forehead and Temple Reconstruction



Forehead and Temple Reconstruction








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The forehead and temple make up a large portion of the face, but there are significant differences between these two adjacent cosmetic units. The forehead is a convex structure with relatively sebaceous, inelastic skin overlying the frontalis muscle. Relaxed skin tension lines (RSTL) tend to run in the same direction as horizontal forehead rhytides except in the central forehead and laterally at the border with the temple. On the other hand, the temple is a concave structure whose overlying skin tends to be thinner, less bound down to the underlying temporalis fascia, and therefore more mobile. The temple is also home to one of the “danger zones” in facial reconstruction: the superficial location of the temporal branch of the facial nerve. The surgeon should be particularly cautious in the use of scalpel or undermining scissors in this region as the nerve runs just deep into the subcutaneous fat from the zygomatic arch to the inferior aspect of the lateral forehead. RSTL on the temple tend to run in a radial direction similar to the direction of periorbital rhytides.



4.1 MEDIAL, LATERAL, AND SUPRAORBITAL FOREHEAD: SIDE-TO-SIDE REPAIR

Smaller defects on the forehead can be closed in a side-to-side fashion. The long axis of the direction of closure (i.e., RSTL) varies depending on the exact location. Defects in the midforehead frequently close easiest in a vertical direction as the frontalis muscle is sparser and considerably weaker in the central forehead (Figs. 4.1A, B, C).






Figure 4.1A. This woman was left with a 0.9 × 0.7 cm defect located on the medial forehead following Mohs surgery for a small basal cell carcinoma.






Figure 4.1B. Closure was accomplished in a vertical direction as the frontalis muscle is much sparser in the central forehead. The wound is more easily closed in this vertical direction (i.e., along relaxed skin tension lines).






Figure 4.1C. Healed result.


In the lateral forehead where the frontalis ends, the RSTL are somewhat mixed. For many defects, closure in the direction of the frontotemporal fusion point is preferred especially if closure in a nonvertical direction might distort a free margin like the eyebrow (Figs. 4.1D, E, F).






Figure 4.1D. This defect on the right lateral supraorbital forehead measures approximately 2.3 × 1.7 cm.






Figure 4.1E. The wound was closed in a side-to-side fashion along the frontotemporal fusion point. The frontalis muscle ends at this point, and relaxed skin tension lines are more mixed in this region.






Figure 4.1F. Final healed view. Closure in this direction avoided deviation of the lateral aspect of the eyebrow.


Defects in the central aspect of the right or left forehead where the belly of the frontalis muscle is thickest can be closed along RSTL in the same direction as the horizontal forehead rhytides (Figs. 4.1G, H, I). Defects up to about 1.0 cm wide can be closed without prolonged upward deviation of the brow, and defects farther (i.e., more superior) from the eyebrow or in older patients can particularly tolerate side-to-side closure without long-term eyebrow elevation.






Figure 4.1G. Defect on the left lateral forehead measures 1.4 × 1.0 cm.






Figure 4.1H. Defect was closed along relaxed skin tension lines in the direction of the horizontal forehead rhytides. Defects of up to approximately 1.0 cm in vertical height (i.e., width of the ellipse) can be closed in this fashion without long-term eyebrow lifting, especially in older patients and for surgical defects more superior on the forehead (i.e., not immediately adjacent to the eyebrow).






Figure 4.1I. Healed result.





4.2 FOREHEAD (EYEBROW): ADVANCEMENT FLAP

As with any surgical defect, one starts by asking, “What is missing?” (Fig. 4.2A). The answer will make it clear as to which reconstruction methods will be successful. As the hair-bearing eyebrow is missing, the only way to successfully reconstruct this defect is to replace or restore the middle of the eyebrow with hair-bearing tissue. As such, grafts or local flaps from the forehead will not provide the necessary tissue. The answer to the question, “Where are you going to find the tissue to restore the defect?” is optimally going to be the ipsilateral eyebrow, either medial or lateral to the defect. The medial eyebrow is a paired feature of the central face and therefore any movement of this structure will be immediately visible, both because of its central location and asymmetry with the contralateral eyebrow. A better option is to recruit from the lateral eyebrow, where movement is not readily noticeable. So the best answer to the question “How are you going to move this tissue to where you need it” is either advancement flap or island advancement flap. Both of these options advance the lateral eyebrow medially, filling the surgical defect and making the eyebrow contiguous. In this case, an advancement flap was selected to minimize potential for trapdoor (as may happen with island advancement flaps) and to maintain cutaneous connection (and possibly better vascular supply) for the hair-bearing flap. This second point might be somewhat controversial as island advancement flaps tend to be very mobile and have a strong vascular pedicle; however, the farther the flap travels, the greater the pedicle may need to be released and therefore the greater the risk to the vascular supply. In any event, an advancement flap was designed to reconstruct the defect (Fig. 4.2B). The inferior incision was placed just inferior to the eyebrow, extending to the lateral upper eyelid where a tricone was excised to facilitate advancement of the flap and fall in the direction of a periorbital rhytide. After undermining widely by blunt dissection and adequate spot electrodesiccation for hemostasis, the flap was advanced and sutured into place with absorbable, buried vertical mattress sutures. This created a tricone or standing cone superior to the eyebrow, which was excised in a vertical direction. The lateral shortening of the eyebrow is barely noticeable, but maintaining the contiguity of the eyebrow is what makes this repair work so well (Fig. 4.2C).







Figure 4.2A. This man was left with a moderate-sized defect after Mohs surgical excision of a basal cell carcinoma involving primarily the midportion of the eyebrow.






Figure 4.2B. An advancement flap is designed to reconstruct the eyebrow. The incision is just inferior to the eyebrow and continues to the lateral aspect of the upper eyelid, where a tricone is excised. After the flap is advanced and sutured into the surgical wound, a tricone or standing cone is also excised on the forehead superior to the surgical defect.






Figure 4.2C. Healed cosmetic result shows contiguity of eyebrow and most scars fairly well hidden.





4.3 LATERAL FOREHEAD: ADVANCEMENT FLAP

Most of the adjacent lax tissue in this location is lateral to the surgical defect (Fig. 4.3A). In addition, by recruiting tissue laterally one minimizes the chance of distortion or lifting of the eyebrow, an oft-forgotten free margin. An advancement flap does not recruit a significant amount of tissue, but there is adequate tissue laterally to close a defect this size with proper mobilization (Fig. 4.3B). One word of advice here is to place the horizontal incision line within or immediately adjacent to a horizontal forehead rhytide. By doing this, a large portion of the surgical scar is optimally hidden on the forehead (Fig. 4.3C). The distal portion of this incision (where the tricone is excised) is at the junction of the forehead and temple. This serves two purposes: improves mobility of the flap (as undermining is carried to the temple) and hides the scar better at the junction of the two cosmetic units. After the flap is advanced and sutured into place, a tricone or dog-ear forms superior to the defect. This is easily excised in a vertical direction.






Figure 4.3A. A surgical defect on the left forehead measures 2.3 × 1.9 cm.







Figure 4.3B. An advancement flap mobilizes lax tissue from the lateral forehead, avoids deviation of the eyebrow, and hides most incision lines.






Figure 4.3C. Short-term healed result shows mild pinkness still remaining along incision line but otherwise well healed.




4.4 LATERAL FOREHEAD (EYEBROW): FULL-THICKNESS SKIN GRAFT

The lateral aspect of the eyebrow is lost in this young woman status-post skin cancer surgery (Fig. 4.4A). As pointed out in Section 4.2, one should avoid moving the medial eyebrow laterally. While moving the mid or lateral brow medially may be acceptable in reconstruction of the medial brow, moving the medial brow laterally will not provide an aesthetic result. The difference between moving the brow medially or laterally is that the former changes the central face, altering a paired central landmark and making the central face asymmetric. The best option here for this particular patient (who wanted to avoid additional scars from creation of a local flap) was a full-thickness skin graft (Fig. 4.4B). A rhombic transposition flap from the temple would have easily recruited adequate tissue to fill the defect but would have created additional incision lines and scars and could have potentially disturbed the position of the eyebrow. The patient was very happy with the result and chose to use eyebrow pencil to finesse the final result (Fig. 4.4C).






Figure 4.4A. Surgical defect of the lateral eyebrow. Patient wished to avoid any procedure that might make additional scars or potentially change the position of the eyebrow.






Figure 4.4B. Repair with a full-thickness skin graft (donor site preauricular cheek, placing incision line in pretragal crease). Graft is sutured into place with 6-0 polypropylene sutures, although 5-0, fast-absorbing gut suture would have worked well. Two tacking sutures at the center of the graft were used to approximate the graft to the wound bed, and four sutures outside of the graft to hold a tie-down dressing in place.

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Oct 13, 2018 | Posted by in Reconstructive surgery | Comments Off on Forehead and Temple Reconstruction
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