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Introduction
CHAPTER 43 Reconstruction of the
Forehead
S. Tyler Hollmig Brian C. Leach
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.
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.
Expert Tips
Multiple defects may be repaired with a Burowโs 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.
Donโt 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.
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.
Patient Education Points
Always gauge a patientโs 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.
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.
CHAPTER 43 Reconstruction of the