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FOREHEAD RECONSTRUCTION

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SUMMARY

  • The forehead, temples, and eyebrows are common locations for nonmelanoma skin cancer and lentigo maligna.

  • An array of closure techniques may be used to close defects in these locations, from linear repairs to complex flaps and grafts.

  • The eyebrow should be conceptualized as a free margin, and repairs should be designed accordingly.

image Beginner Tips

  • Linear repairs should always be favored if feasible, but beware of trying to force a linear repair when free margin distortion could result.

  • Orient linear repairs along the periocular rhytids for medially located temple defects, and in an arciform pattern close to the hairline for lateral temple defects.

  • The benefit of orienting forehead repairs horizontally along the rhytids should be weighed against potential asymmetric eyebrow lifting and the risk of neural compromise.

image Expert Tips

  • Multiple defects may be repaired with a Burow’s advancement flap where the secondary defect is incorporated into the displaced dog-ear.

  • An A-to-T design may be preferable to an H-plasty for large forehead defects.

  • Defects involving periosteum should first be repaired with a hinge flap.

image Don’t Forget!

  • Vertically oriented forehead repairs may be nearly invisible with outstanding suturing and operative technique.

  • The V-Y (island pedicle) flap provides a robust pedicle that is useful for eyebrow and temple reconstruction.

image Pitfalls and Cautions

  • Facial nerve damage is a risk when working deep in the temple; therefore, such repairs require a thorough appreciation of anatomy.

  • Patients should be warned when approaching infiltrative tumors in these locations that permanent facial nerve damage is a possibility.

image Patient Education Points

  • Always gauge a patient’s willingness to undergo and recover from an extensive procedure before it is initiated.

  • The forehead is highly vascular and postoperative ecchymosis is likely.

  • Warn patients that even repairs high on the forehead may lead to a black eye due to a combination of anatomy and gravity.

image Billing Pearls

  • Most flaps on the forehead are coded with 14040 or 14041, and these codes include the excisional component; it is not appropriate to bill both an excision and a flap repair code simultaneously, except for Mohs excision codes.

  • Do not use CPT code 15740 for V-Y (island pedicle) flaps, as this code is only appropriate for flaps based on a dissected and identified named axial vessel.

INTRODUCTION

The forehead, temples, and eyebrows constitute the upper one-third of the face. This anatomic region is bounded by the hairline both superiorly and laterally, and by the nasal root, orbital rim, and zygomatic arch inferiorly.1 It is a region commonly afflicted with cutaneous neoplasia and is of considerable functional and aesthetic importance. As such, it is frequently encountered by the reconstructive dermatologic surgeon, where sufficient understanding of local anatomic features, a thoughtful approach to repair design, and meticulous intraoperative technique represent critical determinants to surgical outcomes.

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