O to T Flap for Central Forehead Defect Reconstruction

[The useful forehead, the impaired forehead, but the forehead… repaired!]

The forehead, although sometimes hidden by a fringe, is a major region of the face revealing many expressions such as fatigue, surprise, concern, anger… In reconstructive surgery, the forehead is frequently used as a donor site. This article looks at three aspects: the used, traumatised and repaired forehead. The forehead, with its high-quality hairless skin and proximity to the noble structures of the face, is a central donor site. The forehead flap is commonly used for nasal reconstruction, with several variations to meet different needs. Other pedicled flaps, such as the supra-eyebrow flap and the crane flaps, are also used for various facial reconstructions. The forehead can be affected by trauma, burns, vascular lesions and skin tumours. We are particularly interested "en coup de sabre" linear scleroderma, an autoimmune disease that causes cutaneous and subcutaneous fibrosis, sometimes associated with Parry Romberg syndrome. In addition, lesions of the temporal branch of the facial nerve lead to muscular paralysis, affecting the aesthetics and function of the frontal region. Precise knowledge of the anatomy of the nerve pathway is crucial to avoid iatrogenic lesions. The entire arsenal of reconstructive surgery is useful for repairing the forehead. Controlled wound healing, tension suturing and the use of local flaps are key techniques for repairing the forehead. Tension sutures are particularly effective for small losses of substance, and their orientation depends on the location. Advancement, rotation and transposition flaps are used for larger losses of substance. Skin grafts, although less aesthetic, are sometimes necessary. Skin expansion, although socially restrictive, is used to treat congenital giant nevi and increase the surface area of forehead flaps.

Simplifying Forehead and Temple Reconstruction: A Narrative Review

The forehead and temporal region are frequent areas of skin cancer development. After tumor removal, reconstruction must be performed, maintaining the frontal-temporal line of the scalp and symmetry of the eyebrows in an attempt to hide the scars within these marks or natural folds and wrinkles. Second wound healing and skin grafts generally do not produce an acceptable cosmetic result. When direct closure is not possible, the technique of choice is skin flaps. In the midfrontal line continuation of the glabella, there is a remnant of skin to be used as a donor area for local flaps; similarly, it occurs in the preauricular cheek, which can move toward the temple. In addition to the classic advancement and rotation flaps, the frontalis myocutaneous transposition flap is an excellent technique for closing defects which are wider than higher on the forehead. Its design is very versatile and can be performed between the two pupil lines at different heights depending on the location of the defect. On the other hand, the preauricular skin advancement flap with an infralobular Burow's triangle is also an excellent option for reconstructing tumors in the temporal area.

Modification of Orticochea Three-Flap Technique for Reconstruction of Lateral Forehead Defect

Surgical defects in temporo-parieto-frontal region are challenging to reconstruct (Ransom in Arch Facial Plast Surg, 2012. 10.1001/archfacial.2012.7). The size and site of the defect determines its mode of reconstruction (Ransom in Arch Facial Plast Surg, 2012. 10.1001/archfacial.2012.7). A 60-year-old lady presented with basal cell carcinoma (BCC) over the skin of the right temporal region. She underwent wide excision of the lesion resulting in a moderate sized skin and soft tissue defect. Reconstruction of the defect was challenging owing to the size not amenable for primary closure, lack of pliability of adjoining soft tissue and proximity to structures of aesthetic significance. In order to achieve a functional and aesthetic reconstruction, a modified Orticochea three-flap reconstruction technique was used. This case report describes in detail the surgical procedure and outcome.

Ultrathin Supratrochlear Artery Cutaneous Branch Flaps for Large Defects Around Eyebrows

BACKGROUND

The key point of repairing large defects around eyebrows is to keep the eyebrow undistorted. The limited skin elevates the application difficulty of conventional methods such as direct suture or local flap. Forehead pedicle flaps do well in tension control. However, most of them are too thick for defects because the frontalis muscle must be included. Recently, 1 stable supratrochlear artery cutaneous branch was found, which provides an opportunity to make an ultrathin forehead flap with a good blood supply. This study aims to investigate whether the supratrochlear artery cutaneous branch flap could perform good esthetic reconstruction for defects around the eyebrow.

METHODS

The authors retrospectively included 15 patients whose defect around the eyebrows was repaired by the supratrochlear artery cutaneous branch flap from June 2017 to June 2020. The authors followed up about their flap color and texture, scar, abnormal sensation, any complication, recurrence, and patient satisfaction for at least 6 months online or face-to-face.

RESULTS

All of the flaps survived, without distortion of the eyebrows or inner canthi. Similar flap color, texture, and thickness with the nearby skin were obtained, except 2 patients reported pigmentation. Donor and receptor scars were acceptable. There was no recurrence or other complications. All of the patients were satisfied with the surgery effect.

CONCLUSIONS

The supratrochlear artery cutaneous branch flap is a valuable alternative method to repair large defects around the eyebrows. It can avoid facial distortion and achieve good esthetic outcomes in single-stage surgery.