Forehead and Temple Reconstruction Treatment & Management
- Author: Desiree Ratner, MD; Chief Editor: Dirk M Elston, MD more...
The basic principles of reconstruction of the forehead and the temple are discussed below. Forehead and temple defects can be repaired by primary closure, skin flaps, skin grafts, tissue expansion, and healing by secondary intention. Subdividing the forehead unit into the midline, the paramedian, and the lateral subunits may assist the surgeon in planning reconstruction of forehead defects.
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In the reconstruction of the forehead unit, recognizing that tissue laxity and mobility are influenced by several factors, including the patient's age and the degree of sun exposure, is crucial. Younger patients may have decreased tissue laxity compared with older patients. In general, dermal thickness and sebaceous gland concentration increase when moving from the hairline to the suprabrow region. To avoid depressed scarring of the lower part of the forehead where the dermis is thinner, wound edge eversion should be maximized. Generally, horizontal wound closure is recommended on the lateral and paramedian aspects of the forehead where surgical scars can be camouflaged in the transverse relaxed skin tension lines and forehead furrows. On the median part of the forehead, because of the presence of the galeal median raphe, vertical closure is recommended.
Forehead laxity can be estimated by pinching the tissue horizontally and vertically. Tissue may be freed by undermining in the mid subcutaneous plane below the dermal plexus or by undermining below the superficial fascia. More tissue is freed by undermining in the mid subcutaneous tissue than by undermining in the fibrous fascia; however, this technique is surgically tedious and bloody because of the presence of the neurovascular bundles in the mid subcutaneous region.
Midline Forehead Reconstruction
Large defects on the central part of the forehead can be repaired by vertical or horizontal primary closure. The type of primary closure is often determined by the orientation of the primary defect and the patient's natural forehead creases. Tissue mobility can be estimated by pinching the wound edges together. In larger defects in which primary closure may be difficult, deep fascial scoring in a vertical orientation may be cautiously attempted to increase tissue mobility. However, if pinching the tissue does not provide complete closure of the primary defect, undermining may not produce additional tissue laxity.
A vertical scar on the central part of the forehead is cosmetically more acceptable than on the paramedian part of the forehead. Vertical incisions on the central part of the forehead often heal with fine, nearly imperceptible scars. The lack of the frontalis muscle fibers in the median raphe and the direction of embryonic fusion planes on the central aspect of the forehead are believed to be responsible for the good cosmetic outcome of vertical scars in this area.
Relatively large defects on the central aspect of the forehead can be vertically closed in a fusiform fashion. Extensive undermining in the subfrontalis plane can be attempted with minimal risk of motor or sensory compromise in this region.
The primary closure of large defects on the central part of the forehead can lead to standing cutaneous deformities, which can often be excised by using a Burow triangle or W -plasty in the glabellar crease.
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This technique may lead to medial displacement of both brows if excessive tissue is removed, and it should be discussed with the patient before surgery. Defects that are slightly lateral to the midline can be widened if necessary to allow closure over the true midline.
At times, midline defects can be closed in a transverse orientation. Horizontal closure is acceptable as long as the medial part of the brow is not elevated; this closure can lead to the patient having a worried look. Brow elevation in older patients may be more cosmetically acceptable than in younger patients. In addition, the brows will likely relax downward after a few months.
Many types of flaps have been used in the reconstruction of midline forehead defects. These flaps include advancement flaps, rotation flaps, transposition flaps, and subcutaneous pedicle flaps.
Advancement flaps used include single or double advancement flaps, A-to-T flaps, Burow triangle advancement flaps, O-to-Z flaps, and bipedicle advancement flaps. Single or double advancement flaps have the advantage of hiding the horizontal incisions in the natural creases and wrinkles on the forehead. If the defect is on the median aspect of the forehead, bilateral advancement flaps may yield a better cosmetic outcome than single advancement flaps. The disadvantage of these flaps is that in younger patients with few horizontal wrinkles, the horizontal incisions are not easily hidden. However, asking the patient to elevate the eyebrows enables the surgeon to ascertain the precise location of the patient's horizontal forehead lines, which become more prominent as the patient ages.
A-to-T flaps are particularly useful in the repair of defects on the upper central aspect of the forehead. The base of the flap can be hidden in the frontal hairline, and, if necessary, the Burow triangles can be hidden in the hair. In younger male patients with androgenetic alopecia, frontal hairline recession must be considered when designing the flap.
Burow triangle advancement flaps are used to repair defects in areas in which anatomical structures are on one side of the defect and should not be pulled or stretched. Therefore, a Burow triangle flap is more often used in the repair of defects on the lateral part of the forehead than in the repair of defects on the central part of the forehead.
O-to-Z flaps may be used to repair defects on the central part of the forehead. The 2 horizontal incision lines are often hidden in the natural creases on the forehead. The disadvantage of this closure is the noticeable central Z portion of the flap and the wide undermining required to advance and slightly rotate the flap.
Bipedicle advancement flaps may be used in the repair of defects on the median and paramedian parts of the forehead close to the hairline. The main advantage of this flap is that it minimizes tension and maintains the horizontal orientation of the primary defect. A percutaneous galeal releasing incision is made 2-3 cm parallel and posterior to the hairline; this incision allows for increased tissue mobility at the site of the primary defect. This full-thickness flap is undermined in all directions and slides into the initial defect. The galea and inframuscular fascia remain unsutured, which allows additional tissue mobility. The disadvantage of the flap is that it can lower the hairline.
Rotation flaps can be unilateral, bilateral-symmetric, or bilateral-opposing. Unilateral and bilateral rotation flaps are used to repair upper mid forehead defects that extend to the hairline or that can easily be extended into the frontal hairline. The advantage of these flaps is that they can mobilize large amounts of tissue to repair large defects. In addition, flap incision lines can be hidden in the hair-bearing area of the frontal part of the scalp. Another advantage is the good viability of the flaps because their pedicles are usually broadly based.
Bilateral flaps are preferred in the repair of larger defects because unilateral rotation flaps can lead to asymmetry. The main disadvantages of rotation flaps are that they lead to lowering of the hairline and to transection of sensory nerves above the incision site, resulting in anterior scalp numbness and lateral brow movement. The long incision lines of these rotation flaps are often out of proportion to the size of the initial defect.
Transposition flaps, such as rhombic flaps and Webster 30° angle flaps, have limited use in the repair of midline forehead defects. Rhombic flaps can be used for midline defects close to the glabella, where skin from the glabellar region can be mobilized into the central part of the forehead. Disadvantages of these flaps include multiple surgical scars that do not camouflage within the lines of the forehead, contour alteration (which partially depends on flap design and dog-ear placement), and excessive wound tension (which may pull on the free margin of the eyebrows).
Subcutaneous pedicle flaps have been used to repair large midline defects. The donor area of the flap is closed side to side, and the resultant scar can be hidden in the natural creases on the forehead. These flaps reportedly have good survival and are useful in the repair of large defects by taking advantage of lateral tissue laxity. Disadvantages of this flap include multiple scars (because incision lines do not tend to follow natural creases), brow elevation as a result of wound closure, and damage to the frontal branch of the facial nerve during pedicle development.
Grafts are used in situations in which the defect is too large for primary closure and flaps cannot be moved to close the primary defect without significant tissue distortion. Skin grafts may be used to cover large forehead defects, or they may be designed as temporary coverage prior to tissue expansion.
Properly selected full-thickness skin grafts may provide good color and texture match for forehead defects. Burow grafts may be used to close small defects, whereas full-thickness grafts taken from the neck or the supraclavicular area may be harvested to repair larger defects. Split-thickness skin grafts usually yield suboptimal cosmetic results; however, in older patients with thin, pale, white skin, the grafts have been reported to have acceptable cosmetic results. A 2012 study reported that extensive forehead and temple defects were successfully repaired in a cohort of elderly patients with split-thickness skin grafts harvested from the scalp, with low morbidity, rapid painless healing, and a high success rate. Split-thickness skin grafts are appropriate in situations in which the patient is at high risk for skin cancer recurrence and requires close surveillance of the tumor site.
Healing by secondary intention
Healing by secondary intention on the forehead often results in poor cosmetic outcome. In areas that have adequate bony support and less skin movement, such as the upper central and lateral one third of the forehead, cosmetic results for healing by secondary intention may be superior.
Intraoperative tissue expansion can be used when the surgical defect is too large for primary closure. A 30-mL Foley catheter, which generates 10-20 mm of tissue in approximately 20 minutes, can be used to perform intraoperative unilateral or bilateral tissue expansion.
Paramedian Forehead Reconstruction
Defects on the paramedian part of the forehead are defined as defects occurring over the convexity of the forehead from the midline to the mid brow. Relaxed skin tension lines in this area are primarily horizontal; however, some patients may have curvilinear or vertical lines. Primary wound closure in this area may be best achieved by horizontal repair within the transverse relaxed skin tension lines because, usually, horizontal closure yields more aesthetically acceptable results in this area than vertical closure. However, in patients who have strong vertical lines, vertical closure may be preferable.
See the images below.
The feasibility of horizontal wound closure may be restricted by the excessive vertical height of the primary defect, by the degree of brow elevation as a result of wound closure, and by the lack of skin and scalp mobility on the paramedian portion of the forehead. The degree of postoperative brow elevation is highly dependent on skin laxity and wrinkling in the patient. As a result of the effects of gravity and skin laxity in older patients, brow elevations of as much as 1 cm can return to a normal symmetric position by several weeks after surgery. Suturing of the brow dermis to underlying periosteum of the supraorbital rim can be used to minimize brow elevation when performing horizontal reconstructions in the paramedian part of the forehead.
Flaps used in the reconstruction of paramedian defects include advancement flaps, rotation flaps, and transposition flaps.
Advancement flaps, such as unilateral or bilateral advancement flaps, A-to-T advancement flaps, Burow advancement flaps, bipedicle advancement flaps, and subcutaneous island pedicle flaps, may be used to repair defects too large to be closed primarily. Advancement flaps may yield excellent cosmetic results, especially if incisions can be placed in the natural creases on the forehead or in the brow lines.
Unilateral or bilateral advancement flaps can be used to repair defects on the paramedian aspect of the forehead.
See the image below.
Bilateral advancement flaps are used for reconstruction of larger defects. Because tissue mobility is increased, the lateral flap may be longer than the medial flap. The disadvantage of these flaps is that if extensive undermining occurs at the deep subcutaneous level, patients may experience sensory denervation.
A-to-T advancement flaps can be used to repair defects on the paramedian part of the forehead. The advantage of this flap is that the base can be hidden in the upper brow hairline. Burow advancement flaps take advantage of lateral tissue laxity. If the primary defect is close to the brow line, the base incision can be camouflaged in the superior margin of the brow.
Bipedicle advancement flaps are used in the closure of paramedian defects when primary closure is not feasible. An incision is made 2-3 cm parallel and posterior to the hairline. Percutaneous galeatomy increases the mobility of the skin tissue. This full-thickness flap is undermined in all directions and slides into the primary defect. The advantage of this flap is that the incision site of the secondary defect is hidden in the hairline, and the flaps tend to be viable and well vascularized. The main disadvantage of this flap is the lowering of the frontal hairline.
Subcutaneous island pedicle flaps may be unilateral or bilateral. Bilateral unipedicle advancement flaps can be used to repair median forehead defects. Disadvantages of this type of closure include difficulty in hiding the lines of closure in the natural creases on the forehead and the possibility of eyebrow elevation as secondary defects are repaired. Taking care not to injure the frontal branch of the facial nerve is important during pedicle development and undermining. Midline island pedicle flaps have also been used to repair suprabrow defects. The flap is swung in a pendulumlike fashion to fill in the primary defect; however, the resultant scar at the site of the initial defect tends to be cosmetically displeasing.
Rotation flaps can be used to repair defects on the paramedian part of the forehead that are close to the hairline where the base of the flap can be hidden in the hairline. The final surgical scars tend not to follow the natural creases on the forehead.
Transposition flaps, such as rhombic flaps, can be used in closure of paramedian defects. Resultant closure lines are aesthetically displeasing unless they are hidden in the hairline. If improperly designed, the flaps can lead to eyebrow distortion.
The use of grafts is limited to situations in which the defect cannot be repaired by primary closure or by flap placement. A full-thickness graft must be matched for texture and color to the area of the defect.
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Healing by secondary intention
The cosmetic outcome of healing by secondary intention in the paramedian aspect of the forehead is suboptimal.
In repair of defects in which primary closure is not possible because of lack of tissue mobility, intraoperative tissue expansion allows excess tissue to be generated, allowing a simple layered repair of the defect. The advantage of tissue expansion is that less tension exists on the final wound.
Lateral Forehead Reconstruction
The lateral portion of the forehead is defined as lateral to the mid brow line, in which the underlying bony curvature goes from flat medially to concave laterally. Primary wound closure on the lateral part of the forehead is best achieved by repairing the defect parallel to the individual's skin lines. In the lateral part of the forehead, skin lines are curvilinear. In younger patients, the lines may be better defined by asking the patient to squint and to elevate the eyebrows. The skin in the lateral part of the forehead may have increased elasticity compared with the median and paramedian parts of the forehead.
The flaps usually used to repair lateral defects include advancement flaps, transposition flaps, rotations flaps, and bipedicle advancement flaps.
Advancement flaps, such as single or bilateral advancement flaps, A-to-T flaps, and Burow wedge advancement flaps, can be used to repair lateral defects with good cosmetic outcomes. Unilateral and bilateral advancement flaps can be designed such that incisions follow the natural lines on the forehead of each patient. A-to-T flaps are preferred in repairing defects in the superior lateral aspects of the forehead, in which the base of the flap can be hidden in the hairline or above the eyebrow and the base of the flap base can be hidden in the brow line or on the supraorbital rim. Burow wedge advancement flaps combine rotation and advancement. The flaps are cosmetically useful in situations in which the surgical scar can be extended to the brow margin; therefore, the incision can be camouflaged along the superior eyebrow margin. Burow triangle advancement flaps take advantage of tissue laxity over the temple. If properly designed, they can have an excellent cosmetic outcome.
Transposition flaps, such as rhombic flaps, can yield good cosmetic results. The flaps take advantage of loose skin from the temple region.
Rotation flaps, such as unilateral and O-to-Z flaps, can result in good scar camouflage. Unilateral flaps can be used such that the curvilinear scar is alongside the temporal part of the hairline. The main disadvantage of rotation flaps is that the resultant scars may not be well hidden in the natural creases of the lateral part of the forehead.
Bipedicle advancement flaps can be used to repair defects on the lateral portion of the forehead that cannot be closed primarily. An incision is made through the galeatomy posterior to the hairline, and, after undermining, the bilateral pedicle flap is advanced to close the primary defect.
Full-thickness grafts are preferred over split-thickness grafts in the repair of defects on the lateral part of the forehead because of their superior cosmetic appearance.
Healing by secondary intention
Healing by secondary intention can result in an acceptable cosmetic outcome in the concave lateral part of the forehead and in the temple region.
Primary closure of temple defects can be cosmetically optimized by placing the suture lines in the relaxed skin tension lines. Depending on the patient's relaxed skin tension lines, the defect can be closed horizontally, vertically, or in a curvilinear fashion.
See the image below.
Temple defect reconstruction takes advantage of the laxity of the tissues of the neck and cheek region. Extensive undermining of flaps in the temple must be performed with caution because the frontal branch of the facial nerve is located above or within the superficial fascia of the frontalis muscle. The following flaps are used in repairing temple defects: advancement flaps, rotation flaps, and transposition flaps.
Advancement flaps can be used to hide surgical suture lines in the preauricular region, and they take advantage of the laxity of the cheek for defect repair. Dog-ears can be redistributed to the postauricular area. M-plasty can be used, with the resultant scars camouflaged in the crow's feet. Burow flaps are good surgical options for repair of temple defects that cannot be closed primarily, with the M-plasty results camouflaged within the crow's feet lines. A-to-T flaps are not used unless the primary defect is large. The base of this flap can be hidden in the hairline. Subcutaneous island pedicle flaps are occasionally used for repair of temple defects. Particular attention must be paid to avoid frontal nerve injury with this flap.
Rotation flaps can yield excellent cosmetic results. These flaps take advantage of cheek laxity. Tissue is rotated upward and medially to close the primary defect. Surgical scars are usually hidden in the preauricular region.
Transposition flaps also take advantage of cheek and neck laxity, and they yield good cosmesis. The advantage of transposition flaps is that the resultant surgical scars are shorter and closer to the initial defect.
Grafts and healing by secondary intention
The use of grafts and healing by secondary intention in the temple area closely resembles the use of these options on the lateral part of the forehead. Healing by secondary intention can result in an acceptable cosmetic outcome in situations in which primary closure or flap placement may not be feasible.
During the initial evaluation, the nature of the patient's lesion, the diagnosis, the prognosis, and the treatment options are discussed in detail. Patients must have a firm understanding of and realistic expectations regarding the procedure. Patients must be instructed in postoperative wound care management so that they can obtain necessary dressings and supplies prior to the surgical procedure and so that they can make necessary arrangements for sick leave from work.
Prophylactic antibiotics are administered to patients with prosthetic joints and other cardiac conditions. In addition, if possible, anticoagulant medications are stopped 2-7 days prior to surgery, but only with medical clearance from the patient's internist or cardiologist. Communication between the surgeon and the internist is of paramount importance in such situations.
Forehead and temple reconstructions are performed under local anesthesia. Lidocaine (1% or 2%) with epinephrine (1:100,000) buffered with sodium bicarbonate may be used.
Postoperative wound care instructions are given to each patient. At the author's institution, patients are given the following instructions:
What to expect after surgery
Discomfort after the surgery is usually minimal. Acetaminophen (Tylenol), 2 tablets every 4 hours, should help relieve any pain.
To lessen the discomfort, to relieve swelling, and to minimize bruising, an ice pack may be applied over the dressing every 2-3 hours for 20 minutes. Elevation of the wound area is also helpful.
A pressure dressing is applied to the wound to prevent bleeding and to minimize swelling. A small amount of blood may be present on the edges of the dressing; this finding is normal. If bleeding persists and soils the dressing, apply firm and constant pressure over the dressing with gauze for 15 minutes. If bleeding persists, repeat the pressure for an additional 15 minutes. In rare instances, if bleeding persists, call the office (office and emergency numbers are provided).
Changing the dressing
The first dressing change should occur approximately 48 hours after the dressing was applied.
During the healing process
Upon removal of the initial dressing, patients may shower and allow the wound to get wet; however, do not allow the forceful stream of water to hit the wound directly. If the wound is on the scalp, hair may be washed with baby shampoo to avoid any irritation.
Avoid aspirin and aspirin products. Avoid alcohol consumption for 2 days after surgery.
The edges of the wound are normally pink and slightly tender to touch.
Mild itching and periodic discomfort may occur around the wound.
Numbness in the area surrounding the surgical site is not uncommon.
If the wound becomes red, hot, or painful to touch, call the office immediately.
Make certain that a sunscreen of at least sun protection factor (SPF) 30 is applied.
Please remember that follow-up visits are important.
Patients are seen in the office 1 week postoperatively for suture removal and at 1 month for a follow-up visit. After the second follow-up visit, patients are referred back to the primary medical dermatologist.
Complications include bleeding, infection, seroma, hematoma, necrosis, and scarring. Additionally, if the superficial temporal branch of the facial nerve is transected, the patient may lose his or her ability to raise the eyebrows.
Outcome and Prognosis
The art of reconstructive surgery lies in the ability of the surgeon to tailor each repair to the individual patient. The goals of the surgeon should be to obtain tumor-free margins and to preserve motor and sensory nerve function, while simultaneously achieving a cosmetically elegant surgical scar. Achieving these goals requires not only a working knowledge of basic anatomy but also a thorough understanding of the principles and practice of soft tissue movement and defect reconstruction.
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Dzubow LM. Temple. Dzubow LM, ed. Facial Flaps Biomechanics and Regional Application. Norwalk, Conn: Appleton & Lange; 1990.
Siegle RJ. Reconstruction of the forehead. Baker SR, Swanson NA, eds. Local Flaps in Facial Reconstruction. St. Louis, Mo: Mosby; 1995. 421-42.
Tromovitch TA, Stegman SJ, Glogau RG. Forehead. Tromovitch TA, Stegmen SJ, Glogau RG, eds. Flaps and Grafts in Dermatologic Surgery. Chicago, Ill: Yearbook Medical; 1989. 83-92.
Hussain W. The contralateral subgaleal sliding flap for the single-stage reconstruction of large defects of the temple and lateral forehead. Br J Dermatol. 2014 Apr. 170 (4):952-5. [Medline].
Quilichini J, Benjoar MD, Hivelin M, Lantieri L. Split-thickness skin graft harvested from the scalp for the coverage of extensive temple or forehead defects in elderly patients. Arch Facial Plast Surg. 2012 Mar. 14(2):137-9. [Medline].
Goldberg LH, Silapunt S, Alam M, Peterson SR, Jih MH, Kimyai-Asadi A. Surgical repair of temple defects after Mohs micrographic surgery. J Am Acad Dermatol. 2005 Apr. 52(4):631-6. [Medline].