Geometric Reconstructive Surgery of The Temple and Lateral Forehead: The Best Election for Avoiding a Graft

Anatomically, the temple and lateral forehead is an embryonic fusion plane where tumors may develop with a high degree of invasion and infiltration. Although most basal cell carcinomas (BCCs) in the temple are well defined, patients may present with aggressive or neglected tumor exhibiting extensive invasion, and the preferred treatment is Mohs micrographic surgery (MMS). Repair options for the temple and lateral forehead include second-intention healing, primary closure, skin grafting, and local tissue rearrangement.

In elderly patients, who have more redundant skin, larger defects can often be closed primarily without excessive wound-closure tension. Second-intention healing on the lateral forehead and temple heals with only satisfactory results, and proximity to the eyebrow must be considered because scar contraction may result in brow elevation. Split- and full-thickness skin grafts do not usually give satisfactory results. These grafts are usually patch-like on an otherwise ungrafted face, and their edges are their major shortcoming unless hidden along natural lines. Skin grafts provide a poor match in thickness and color, and at best should be considered a temporary measure. After surgery, larger temple defects are best repaired with flaps. Single- or double-transposition flaps are commonly performed in the lateral forehead region to close skin defects, taking advantage of excess tissue in the temple. Advancement and rotation flaps are excellent for temple reconstruction because they take advantage of the curvature of the skull. The cheek, median forehead, and temple are excellent reservoirs of skin, which are larger with older patient age, and they have a greater laxity than other anatomical areas, with a rich vascular network that allows a large superficial area to be lifted with a low risk of necrosis.

Cheek advancement flaps have the advantage of the relative mobility and elasticity of the skin and soft tissue of the cheek. Oncologic facial reconstruction requires understanding regional anatomy and tissue movement. Here we describe a series of flaps and dog ears to close a large defect in the temple and lateral forehead. The defects were segmented, and the mobility of the surrounding tissue was determined. The mobility was used to plan local advancement, rotation, or transposition flaps with their Burow's triangles.

CITATION  Dermatol Surg. 2008 Nov;34(11):1553-60