Chapter 7: Lateral Forehead

INTRODUCTION

Skin laxity is relatively modest on the lateral forehead due to the inelastic fascial sheath encasing and adjacent to the frontalis muscle. Therefore, defects that are unable to be closed with a primary repair will need to access the laxity from the temple or preauricular area.^1–3

The temporal branch of the facial nerve can be damaged during surgery on the lateral forehead and temple. To minimise the risk of injury to the nerve, undermining should be relatively superficial in the subcutaneous fat plane above the frontalis muscle and the superficial musculoaponeurotic system. Of note, the superficial temporal artery runs in the subcutaneous plane in the temple area. The route of this artery and its branches can be marked and anticipated by palpation prior to incision.

For small defects, side-to-side linear repairs are commonly possible. Horizontal closures are ideal for defects less than 1 cm and centred on one of the horizontal creases as the scar can be placed in the crease. The inferior border of the lateral forehead, however, is close to the eyebrow, where horizontal repair can lead to eyebrow elevation. The elevation may be temporary if the immediate postoperative elevation is less than approximately 5 mm in younger patients and less than 1 cm in older patients. Lateral eyebrow elevation is more likely to resolve than medial eyebrow elevation. Defects higher up on the forehead are less likely to produce eyebrow elevation than defects at the suprabrow.

In patients with larger defects on the lateral forehead, vertical side-to-side and flap repairs can be considered. Grafts and second intention healing are necessary in some cases but have variable cosmetic impact.

Vertical side-to-side closures can heal satisfactorily on the lateral forehead as well as on the central forehead, despite the fact they are oriented perpendicular to relaxed skin tension lines. Vertically oriented linear repairs also mitigate the risk of the V-shaped scalp numbness and the bending inwards of the horizontal folds towards the scarline that occur with horizontal closures. Vertical closures also prevent eyebrow displacement but should generally not extend into the eyebrow, and are therefore not often used for defects at the suprabrow. A vertical white scar, however, can be obvious and care needs to be taken to realign the horizontal forehead creases.

On the superolateral part of the lateral forehead there are often oblique creases created by sleeping with the head on the side on a pillow. Small- to medium-sized defects can be closed side to ...