Large Defect Forehead Reconstruction: Aesthetic Unit Principles For Reconstruction
Ainsley L. Taylor, BS, Alexander H. Sun, MD, MHS, Buthaniah Al-Shunnar, MD, Michael Baumholtz, MD, Navin Singh, MD, Maurice Nahabedian, MD, Gene Deune, MD, Anthony Tufaro, MD, DDS, Michael Yaremchuk, MD, Eduardo D. Rodriguez, MD, DDS, Paul N. Manson, MD, Sashank K. Reddy, MD, PhD.
Johns Hopkins University, Baltimore, MD, USA.
PURPOSE: Classic methods utilizing skin grafts for reconstruction of large forehead defects can result in contour deformity without animation or uniformity of color, leading to a sub-optimal outcome for facial expressions. This study defines the aesthetic units of the forehead and describes reconstructive options for optimal aesthetic outcomes.
METHODS: This is a retrospective review of patients who underwent large forehead reconstruction at the Johns Hopkins Hospital. Patients were categorized by overall quality of reconstruction, adequacy of thickness and color match, durability, and complications.
RESULTS: 104 procedures were performed on 90 patients using one of nine reconstructive flap options. Outcomes were compared to 42 patients previously treated with skin grafts. For central defects, optimal management utilized a separation of components, frontal parietal advancement, hemicoronal advancement, bicoronal advancement, multiple local flaps, or free tissue transfer. Lateral defects were managed best by cervicofacial advancement, temporoparietal island flap advancement, or a combination. Defects in either aesthetic unit were managed by the "Crane Principle." There was no total flap loss. Partial flap loss in local or axial flaps occurred in 9 patients. Two free flaps returned to the operating room for anastomotic revision.
CONCLUSION: This study classifies the forehead into aesthetic units and offers an algorithm of common reconstructive options for large forehead defects. Overall, local flap reconstruction exceeded the results of skin grafts or free flaps in terms of color, thickness, and texture match. Long-term stability of flaps exceeded skin grafts or skin grafts over muscle flaps.
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