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).

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).

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.

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).

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.

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).