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INTRODUCTION

REPAIR OPTIONS: CENTRAL FOREHEAD

  • Side-to-side closure—often vertical

  • Advancement flaps

    • Unilateral single-sided (L-plasty)

    • Bilateral single-sided (T-plasty)

      • ‘Batman’ variant

    • Unilateral two-sided (U-plasty)

    • Bilateral two-sided (H-plasty)

    • Bipedicle (‘bridge’)

  • Rotation flap

  • Island pedicle flaps

    • Subcutaneous

    • Myocutaneous (frontalis-based)

  • Skin graft

  • Combined repairs

    • Partial closure plus Burow’s graft

    • Partial closure plus second intention

 

Preferred option when a standard side-to-side closure is not possible

Sometimes a side-to-side closure can still be used for a medium to large defect

The central forehead is a cosmetically sensitive location due to potential visibility of any scar. Side-to-side closure is normally feasible for small defects while there is often sufficient laxity, particularly in older patients, to close even large defects this way. This area often lacks the horizontal creases of the lateral forehead in which case, even for larger defects producing longer scars, a vertical orientation will usually produce a less-conspicuous scar than a horizontal orientation. If a side-to-side closure is not possible, advancement, rotation and island pedicle flaps are viable options.

If the defect is very large, a bilateral advancement or rotation flap of the forehead may be the preferred closure option. Partial closure in a side-to-side manner, with either a Burow’s graft from skin redundancies or second intention healing for the residual defect, is another option. A split-thickness skin graft is rarely used in this area due to suboptimal cosmetic results.

Anatomical subunits of the forehead

SIDE-TO-SIDE CLOSURE—OFTEN VERTICAL

Vedio Graphic Jump Location
Midline Side-to-Side Closure (Small Defect)
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Vedio Graphic Jump Location
Midline Side-to-Side Closure (Large Defect)
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Advantages

  • Suitable for closure of small, medium and some large defects

  • Scars commonly fade in this area

  • May hide the scar in forehead rhytides—upper part of this subunit often lacks conspicuous horizontal relaxed skin tension lines due to inferior extension of the median galeal raphe

Disadvantages

  • Long, central scar when defects are large—Z-plasties, as well as inferior W-plasty in the glabellar frown lines, may make scarlines less evident

  • May produce a tight forehead

  • May elevate the eyebrows medially

  • May reduce the distance between eyebrows when glabella is involved

Technique

  1. Use skin hooks or forceps to evaluate ability to close the defect in a side-to-side manner with minimal tension. Choosing the orientation of the ellipse depends on the location of the defect, amount of skin laxity and presence of horizontal rhytides to hide the scar within.

  2. Incise the ellipse. For large defects, place the triangular cones in sterile saline to be used as Burow’s grafts if the defect will not ...

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