Local Flaps in Facial Reconstruction

E
E, Postoperative result at 3 months. (Cour­
tesy of Shan R. Baker, MD.)
FIGURE 20-17, cont’d  ■
FIGURE 20-18  ■  A, A 4 × 3-cm defect of medial cheek and lower eyelid. Rotation advancement flap designed for repair. B, Flap elevated
in a subcutaneous plane. Preauricular incision extended to lobule of ear. Flap reflected inferiorly. C, Flap in place with standing
cutaneous deformity parallel to melolabial crease. D, Postoperative result at 12 months. Persistent fullness of medial cheek due to
incomplete removal of standing cutaneous deformity.
A
B
C
D

FIGURE 20-19  ■  Cervicofacial rotation advancement flap designed for large medial cheek defect. Standing cutaneous deformity
excised in melolabial crease. Incision for flap may extend into neck skin crease or posterior to ear along postauricular hairline.
Posterior
hairline
incision
optional
Z-plasty
optional
A
B
FIGURE 20-20  ■  A, Melanoma in situ of cheek. B, A 4 × 5-cm skin defect after excision. Defect involves zygomatic and buccal aesthetic
units of cheek.
Continued

548
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
C
D
E
F
C, Cervicofacial rotation advancement flap designed for reconstruction. Incision line extends to lower neck to
create large flap. Flap has slight bilobed configuration to place incision line more posteriorly. D, Flap in place. Back cut made at
base of flap to reduce wound closure tension. E, Standing cutaneous deformities excised in second stage to ensure vascularity of
flap at time of initial flap transfer. F, Postoperative result.
FIGURE 20-20, cont’d  ■

20  RECONSTRUCTION OF THE CHEEK
549
FIGURE 20-21  ■  A, A 4 × 3-cm skin defect of medial cheek. B, Subcutaneous tissue pedicle island advancement flap designed for
repair. C, Flap advanced and wound closed. D, E, Postoperative views at 1 year, 3 months. No revision surgery performed. (Courtesy
of Shan R. Baker, MD.)
A
B
C
D
E

550
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
A skin graft may be required for reconstruction when
cutaneous defects of the medial cheek are too large to be
repaired with island advancement flaps or with flaps con­
sisting of skin from the posterior cheek and superior
neck. Skin grafting is infrequently used for cheek recon­
struction because it generally provides inferior aesthetic
results compared with the use of local flaps. However,
skin grafting is particularly useful for repair of very large
cutaneous defects and defects secondary to malignant
disease that require careful surveillance of the area
involved with the malignant neoplasm. The most fre­
quent example of this situation is a patient with mela­
noma who may require wide surgical margins and
prolonged surveillance. Skin grafts used for this purpose
usually consist of a full-thickness graft, which may be
harvested from a number of sites. The preauricular region
of the opposite cheek provides skin with excellent color
and textural match to native skin and allows the resultant
donor scar to be well camouflaged in a pretragal crease.
Postauricular skin provides a graft with a reasonable color
match to the skin of the cheek and offers an inconspicu­
ous donor site scar. The supraclavicular fossa provides an
abundant source of skin with good color match to cheek
skin and ensures a donor site scar easily hidden under
clothing. The contralateral melolabial fold is also a donor
source of skin grafts and provides the best possible color
and textural match to the skin of the medial cheek. Split-
thickness skin grafts contract more than full-thickness
grafts and provide poorer aesthetic results. Split-thickness
grafts often result in a thickness mismatch between native
cheek skin and the graft. However, when a large skin graft
is necessary, split-thickness grafts can more easily be har­
vested than full-thickness grafts.
BUCCAL CHEEK DEFECTS
The buccal aesthetic unit consists of the skin of the
central cheek immediately lateral to the skin of the melo­
labial fold. Defects of this region may be reconstructed
with cutaneous flaps harvested from cheek skin located
superior or lateral to the buccal area. When possible, skin
from the cheek medial to the buccal area should not serve
as the donor site for flaps used to repair buccal defects
because of the likelihood of distorting the melolabial fold.
Primary wound closure is a useful technique for repair­
ing small (1 cm or less) buccal skin defects. The princi­
ples of primary wound closure of small buccal cheek
defects are similar to those described for the medial cheek
aesthetic unit. The central location of the buccal aesthetic
unit of the cheek causes difficulty with positioning of
scars along aesthetic boundary lines when cutaneous flaps
are designed. Because many small defects resulting from
micrographic surgery are circular or oval, primary wound
closure in the form of an ellipse that parallels RSTLs is
the preferred technique. Some defects that are close to
the melolabial crease can be repaired with the scar placed
in the crease. Asymmetric undermining is useful to reduce
the tendency to displacement of the scar laterally toward
the center of the buccal aesthetic unit. Defects that are
not immediately adjacent to the melolabial crease but are
in reasonable proximity can be repaired with flaps that
enable placement of the resulting scar in the melolabial
crease. This is accomplished by excising intervening skin
between the defect and the crease and using wide asym­
metric skin undermining (see Fig. 20-3).
Medium-sized (2 to 3 cm) defects that have a linear
axis parallel to RSTLs can often be repaired primarily
(Fig. 20-22). There are a multitude of cutaneous flaps
that can be used to reconstruct medium-sized defects of
the buccal area when primary wound closure is not ideal.
Many of these flaps are of the transposition or advance­
ment type. The disadvantage of such flaps is that the
resulting scars often lie in the center of the aesthetic unit
and are oriented in several different directions so that
portions of the scars are not aligned with RSTLs. The
main transposition flaps used in cheek reconstruction are
reviewed here, and only key points are highlighted
because details of these flaps are covered elsewhere in this
volume. In general, the authors prefer pivotal advance­
ment flaps or primary closure rather than transposition
flaps for medium-sized defects.
The classic Limberg flap was constructed as a rhombus
with two 60° and two 120° internal angles. The geometry
of the flap is precise and requires a 60° to 120° rhombus-
shaped defect for the flap to properly close the cutaneous
defect.9 The Dufourmentel variant of the Limberg flap
enables repair of defects with less excision of normal skin
to create a rhombus-shaped defect. Like the Limberg
flap, the Dufourmentel flap requires a defect with a
rhombus configuration; however, the internal angles of
the defect may vary from the 60° and 120° angles required
for the Limberg flap.10
The Webster modification of the Limberg flap uses an
M-plasty at the base of the flap to limit the length of exci­
sion of the standing cutaneous deformity formed when the
flap is transferred. For wound closure, the flap relies on
both primary and secondary tissue movement.9,11
The note flap is an angular transposition flap designed
to repair a circular defect. The flap is designed by drawing
a line tangent to the defect for a distance of approxi­
mately 1.5 times the diameter of the circular defect the
flap is designed to repair. A second line drawn from the
end of the first line extends back toward the defect at a
60° angle to the first line. When the flap is transposed
into position, a standing cutaneous deformity will result
adjacent to the base of the flap and requires excision. The
note flap is best used for closure of small circular defects
of 1.5 cm or less but can be used to repair defects as large
as 3 cm.
Bilobe flaps are double transposition flaps and consist
of the movement of two flaps over an incomplete bridge
of tissue.12-14 The flap may be designed in a number of
different ways; the details of these designs are discussed
in Chapter 10. Bilobe flaps designed with a limited pivotal
arc of approximately 90° are most commonly used. The
flap may be designed by creating multiple adjacent rows
of circles around the defect, with the first row of circles
having a surface area 80% of the defect size. A second row
of circles peripheral to the first row is constructed with a
surface area that is 70% of the defect size. The circles
provide a template on which to design a bilobe flap. The
first row of circles represents alternative positions for
designing the first lobe of the flap. The second row of

20  RECONSTRUCTION OF THE CHEEK
551
FIGURE 20-22  ■  A, B, Two skin defects of buccal aesthetic unit oriented parallel to RSTLs. Primary wound closure planned. Anticipated
standing cutaneous deformities marked by horizontal lines. C, Wound repaired. D, Postoperative result at 6 months. No revision
surgery performed. (Courtesy of Shan R. Baker, MD.)
A
B
C
D

552
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
circles represents the size and possible locations of the
second lobe of the flap. Selection of a circle from the first
row for the first lobe of the bilobe flap dictates that the
immediately adjacent circle from the second row will
serve as the template for the second lobe of the flap. Circle
selection and thus location for the flap design depend on
the facial structures in the vicinity of the defect and the
skin laxity in the area of the circles. The surface area of
the circles is less than that of the defect because closure
of the entire wound (defect plus donor sites of the lobes)
depends in part on secondary tissue movement.
Cheek pivotal advancement (noncurvilinear) and cer­
vicofacial rotation advancement (curvilinear) flaps have
been discussed, and the principles for their use to repair
buccal defects parallel those guiding their use for medial
cheek defects. The leading border of the flap will lie in
the center of the aesthetic region of the cheek (Fig.
20-23). This is in contrast to advancement flaps used to
reconstruct medial defects, where the flap may often be
advanced to the nasofacial sulcus and melolabial crease
with minimal sacrifice of normal tissue. This is not prac­
tical in repairing most defects of the buccal unit of the
cheek because of its central location.
Repair of large (more than 3 cm) cheek defects of the
buccal area of the cheek that cannot be repaired with
cervicofacial rotation advancement flaps may require the
use of a full-thickness skin graft. Skin grafting techniques
are similar to those performed at other locations on the
face, and no special considerations exist. Meticulous
hemostasis is always required to prevent hematoma for­
mation as the initial survival of the graft relies on imbibi­
tion. Sewn-on bolster dressings and tacking sutures to
anchor the graft to the wound bed are helpful techniques.
Bolster dressings may consist of Vaseline or Xeroform
gauze configured in a dome over the graft. The bolster
is secured over the skin graft by interrupted sutures that
are tied over the bolster in a radial fashion. Skin grafting
and the use of skin grafts in combination with local flaps
are discussed in Chapters 15 and 16.
LATERAL DEFECTS
The lateral aesthetic unit of the cheek represents the
region between the buccal unit and the auricle. The unit
is covered with skin that adheres more to the underlying
fascia compared with the skin of the buccal and medial
units of the cheek. Skin is less redundant, and the ear,
which is immediately lateral, is immobile and does not
offer a potential source of cutaneous flaps for repair of
defects.
Primary wound closure and transposition flaps are
options for reconstruction of small (1 cm or less) lateral
cheek defects and have been discussed. When wounds are
closed primarily, the scar should be positioned in the
preauricular crease when possible. This location provides
maximum scar camouflage, particularly in older individu­
als, in whom a fold often exists. In men, the edge of the
beard provides a useful location for scar placement.
Medium-sized (2 to 3 cm) cutaneous defects of the
lateral unit of the cheek may be reconstructed with local
flaps having a number of flap designs. Cheek advancement
flaps are useful for closure of preauricular defects. The
cheek skin in the vicinity of the defect is undermined in
the subcutaneous tissue plane, with care taken to preserve
the subdermal plexus. If the defect is circular, standing
cutaneous deformities will develop and need to be
removed; they often can be positioned in a preauricular
crease. Inferior lateral defects can often be closed by
advancing cervical skin upward toward the ear, with the
resultant scar positioned in a preauricular crease (Figs.
20-24 and 20-25). If possible, skin defects in proximity to
the preauricular crease but not immediately adjacent to
the crease are enlarged, discarding the preauricular skin
such that the scar can be placed preauricularly rather than
in the middle of the aesthetic unit (see Fig. 20-3).
An O-T wound repair can be used for closure of
medium-sized defects of the lateral aesthetic unit of the
cheek and requires the use of modified bilateral advance­
ment flaps. The technique is used to close circular and
triangular defects with a resultant T-shaped scar. If the
base of the defect is near the border of an aesthetic unit,
the defect is enlarged so that it will extend to the border.
Use of an O-T wound repair prevents the alignment of
all scars in RSTLs. Defects in the superior aspect of the
lateral aesthetic unit can occasionally be closed with the
scar hidden in the lateral canthal crow’s-feet.
Cervicofacial rotation advancement flaps are probably
the most useful flaps for reconstruction of large (more
than 3 cm) lateral cheek defects. An incision is made from
the lateral border of the defect toward the preauricular
crease and is then curved inferiorly along the ear lobule
into the neck along a skin crease. Making the incision in
a skin crease of the lateral neck provides the flap with
greater mobility than when the incision is placed along
the postauricular hairline and border of the trapezius
muscle. A more anterior positioning of the incision also
creates a donor site that is easier to close, but extending
the incision behind the ear and along the postauricular
hairline often provides better scar camouflage (Fig. 20-26).
The flap is elevated in a subcutaneous plane and for sig­
nificantly large defects can be extended toward the clav­
icle to allow greater mobilization. A drain is often placed
to minimize the risk of seroma and hematoma formation.
A standing cutaneous deformity is created medial and
inferior to the defect as the flap is moved toward the
defect and can pose a challenge because of a tendency for
the deformity to extend into the central portion of the
cheek. The standing cutaneous deformity may be excised
but is often intentionally maintained, primarily to opti­
mize vascularity to distal aspects of the flap, and excised
at a later date under local anesthesia (Fig. 20-27). An
M-plasty is useful in reducing the length of the scar
resulting from excision of the deformity.
ZYGOMATIC CHEEK DEFECTS
The zygomatic aesthetic unit of the cheek is the region
of the cheek between the buccal unit and the temple. It
represents the skin covering the zygomatic arch and
malar eminence. Areas that usually provide the most
mobile skin for construction of flaps used to repair
Text continued on p. 557

20  RECONSTRUCTION OF THE CHEEK
553
FIGURE 20-23  ■  A, B, A 4 × 5-cm melanoma in situ marked for excision. Large cervicofacial rotation advancement flap designed for
repair after excision. Anticipated standing cutaneous deformity marked with horizontal lines. C, Melanoma excised, flap dissected.
D, Flap in place. Standing cutaneous deformity excised parallel to melolabial crease. E, Postoperative result at 6 months. No revision
surgery performed. (Courtesy of Shan R. Baker, MD.)
A
B
C
D
E

554
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 20-24  ■  A, A 3.5 × 2.5-cm skin defect of lateral cheek. Broken lines indicate incisions for advancement flap used for repair of
wound. Superior portion of wound closed primarily. B, Flap in place. Standing cutaneous deformities removed from either side of
flap base. C, Postoperative result at 1 month. (Courtesy of Shan R. Baker, MD.)
A
B
C
FIGURE 20-25  ■  A, A 3 × 4-cm skin defect of lateral cheek. Large arrows indicate direction of advancement. Triangles represent antici­
pated excision of standing cutaneous deformities resulting from advancement. B, Skin advanced and deformities excised. C, Post­
operative result.
A
B
C

20  RECONSTRUCTION OF THE CHEEK
555
FIGURE 20-26  ■  A, A 3.5 × 3-cm skin defect of lateral cheek. Rotation advancement flap designed for repair. Anticipated standing
cutaneous deformity marked with horizontal lines. B, Flap dissected in subcutaneous plane. C, Flap in place. D, Postoperative result
at 7 months. No revision surgery performed. (Courtesy of Shan R. Baker, MD.)
A
B
C
D

556
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 20-27  ■  A, A 6 × 5-cm defect of the lateral cheek. Broken
line represents incision made to create rotation flap. Flap ele­
vated in subcutaneous plane. B, Flap in place. Standing cutane­
ous deformity maintained and excised 3 weeks after initial
operation. C, Postoperative result at 7 months.
A
B
C

20  RECONSTRUCTION OF THE CHEEK
557
cutaneous defects of the zygomatic aesthetic unit are
located in the temple and buccal areas. Care is taken not
to distort the lateral canthus or lower eyelid when cutane­
ous defects of this unit are reconstructed.
Primary wound closure is an effective method of
repairing small (1 cm or less) defects of the zygomatic
unit. The prominent wrinkles created by the action of the
orbicularis oculi may often be used to hide scars resulting
from wound closure. For primary wound closure, an
ellipse is designed incorporating the defect and having a
linear axis that is parallel to the crow’s-feet wrinkles. To
assist with incision planning, the exact orientation of the
wrinkles may be exaggerated by having the patient force­
fully close the eyes. Although elliptical excisions may be
performed for primary repair of laterally located zygo­
matic defects, defects near the periorbital skin may
require an M-plasty to prevent extension of the excision
of the ellipse into the lateral canthus or lower eyelid skin.
The M-plasty allows removal of the skin that gathers
medially without distorting the eyelid. The facial lines
used for incisions to create local flaps to close defects in
the periorbital region generally create vectors of force
that are parallel and lateral to the eyelid, minimizing risk
of postoperative lower eyelid retraction, but the surgeon
should be cognizant of possible eyelid distortion when
designing local flaps in this region. Skin flaps advanced
toward the periorbital area are often secured to the peri­
osteum of the inferior bony orbital rim to prevent exces­
sive tension on the eyelids.
Transposition flaps are very useful for reconstruction
of medium-sized (2 to 3 cm) cutaneous defects of the
zygomatic unit (Fig. 20-28). Transposition flaps have
been discussed before, and their design and implementa­
tion are the same for the zygomatic region of the cheek.
However, the use of transposition flaps requires more
forethought in this region to provide low-tension wound
closures that do not distort the eyelid or lateral canthus.
Particular attention is paid to the vectors of wound
closure tension and lines of maximal extensibility. As an
example, there are fewer alternative rhombic flaps that
may be used to repair a defect in this area compared with
a similar-sized defect in the buccal aesthetic unit. This is
related to the inability to recruit skin from the periorbital
area.
The temporal branch of the facial nerve is relatively
superficial in the zygomatic region (see discussion in
Chapter 21), and the plane of dissection must be more
precise to avoid injury to the nerve. Consisting of
three to five branches, the temporal branch of the facial
nerve traverses the midportion of the zygomatic arch.
These branches are superficial relative to other branches
of the facial nerve. Several methods have been used to
determine their location. Correia and Zani describe tem­
poral branches crossing the arch in the zone formed
by a triangle with the apex at the ear lobe and the
base formed by a line extending between the lateral brow
and the temporal hairline. The temporal branches cross
the zygomatic arch 2 cm posterior to the anterior end of
the zygomatic arch, approximately one fingerbreadth
posterior to the lateral bony orbital rim. The most pos­
terior branch lies approximately 1.8 cm anterior to the
anterior aspect of the helix. Owing to the proximity of
the temporal branches to the surface of the skin of the
zygomatic aesthetic unit, skin flaps are elevated above the
temporoparietal fascia in the superficial subcutaneous fat
immediately beneath the skin without injury to the sub­
dermal vascular plexus. When transposition flaps are used
to repair skin defects of the zygomatic area, a standing
cutaneous deformity is often formed inferiorly. Depend­
ing on the precise location of the defect, the deformity
may extend into the midportion of the cheek, and the scar
from excision may be more conspicuous. An M-plasty
may be used in this situation to reduce the inferior extent
of the scar.
Large (3 cm or more) defects of the zygomatic aes­
thetic unit can often be repaired with transposition flaps
or rotation advancement flaps. Flap design and dissection
are similar to those described for repair of large cheek
defects located elsewhere.
MULTIREGIONAL CHEEK DEFECTS
Periorbital and Cheek Defects
Cutaneous defects that extend from the cheek into the
lower eyelid obviate the decision regarding placement of
incisions in the subciliary line versus along the inferior
bony orbital rim (see Figs. 20-11 and 20-18). Properly
designed cheek flaps can resurface both defects effec­
tively. The extent of the eyelid defect in terms of thick­
ness must be assessed. Tacking the cheek flap to the
periosteum of the inferior or lateral bony orbital rim
avoids excessive inferior pull by the flap on the lower
eyelid margin. In patients with poor lower eyelid muscle
tone, lid tightening procedures or auricular cartilage
grafts may be used to support the eyelid. Auricular carti­
lage is used in patients at risk for eyelid retraction or
secondarily in patients who have suffered unexpected
eyelid retraction after repair of a cutaneous defect of the
eyelid. Lower eyelid retractions are difficult to treat, and
addressing them early while they are less severe and
before permanent scar contracture occurs is advanta­
geous. The use of a lateral canthopexy or superior reti­
nacular suspension to tighten the lower eyelid is advisable
in older patients during the process of reconstruction of
lower eyelid defects that extend into the cheek.
Nasal and Cheek Defects
Cutaneous defects of the medial cheek that extend into
the nose are best reconstructed by repairing each aesthetic
region independently. The most common scenario
involves repair of skin defects of the medial cheek and
lateral nasal sidewall or ala. Reconstruction of these
complex cheek and nasal defects usually calls for the use
of an advancement cheek flap to repair the cheek compo­
nent of the defect and a separate flap or skin graft to repair
the nasal component of the defect (Figs. 20-29 and 20-
30). When a cheek advancement flap is used, the flap is
advanced medially to the nasofacial sulcus and the under­
side of the flap is tacked to the periosteum of the nasal
process of the maxilla to minimize effacement of the
nasofacial sulcus. If the nasal portion of the defect is small,

558
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 20-28  ■  A, A 2.5 × 3-cm skin defect of zygomatic aesthetic cheek unit. Transposition flap designed for repair. B, C, Flap incised
and transposed. D, Wound closed. Standing cutaneous deformity excised superior and lateral to defect. E, Postoperative result at
5 months. (Courtesy of Shan R. Baker, MD.)
A
B
C
D
E
undermining of the nasal skin may allow primary closure
with the resulting scar in the nasofacial sulcus. Larger
defects that cannot be repaired primarily may be repaired
with a full-thickness skin graft or an interpolated parame­
dian forehead flap, depending on the size and depth of the
nasal defect. For medial cheek defects that also require
full-thickness repair of the ala, staging the reconstruction
by repairing only the cheek defect at the first operation is
considered. Surgical staging during a period of a few
weeks allows any lateralization of the cheek flap to occur,
resulting in a stable cheek platform on which to construct
the ala. This minimizes the risk of any lateralization of
the alar base that can occur when both defects are repaired
at the same setting (see Fig. 20-30). Staging must be bal­
anced with the patient’s desires and ability to tolerate
multiple surgical procedures.
Contour Defects: Subcutaneous Adipose Flap
and SMAS Flap
The SMAS is a fibrofatty tissue layer that supports the
overlying skin. The SMAS is infrequently involved with
cutaneous malignant neoplasms and is therefore usually

20  RECONSTRUCTION OF THE CHEEK
559
discontinuous at the zygomatic arch but is present in the
temporal region in the form of the temporoparietal fascia
and then as the galea of the scalp. A flap of SMAS tissue
is elevated superficial to the zygomaticus major muscle
to prevent injury to the buccal branches of the facial
nerve. When the SMAS is undermined laterally to medi­
ally, the zygomaticus major is most easily and safely
identified at its origin from the zygoma. The muscle is
then followed inferiorly, remaining superficial to the
muscle to protect the facial nerve branches that innervate
the muscle on its deep surface. Because the SMAS invests
the zygomaticus major, the natural plane is to continue
beneath the zygomaticus major. This path of least
resistance must be avoided, and a transition to a more
available for use in reconstruction of defects after micro­
graphic surgery. SMAS defects occur only in more
advanced tumors that require deeper resection. In these
more advanced cases, two options exist for addressing
contour problems that may occur after reconstruction.
The surgeon may dissect the flap used for the repair in a
deeper tissue plane, including a greater amount of sub­
cutaneous fat within the flap. When sufficient subcutane­
ous fat is not available, the other option is to dissect the
SMAS flap independent of a cutaneous flap. The SMAS
flap is used to fill the depths of the wound; the skin flap
is used to cover the defect. The SMAS extends over the
cheek, inserting at the melolabial crease, and is continu­
ous with the platysma inferiorly. Superiorly, the SMAS is
FIGURE 20-29  ■  A, Skin defect of medial cheek and nasal sidewall after excision of basal cell carcinoma. B, Cervicofacial rotation
advancement flap designed for repair. Superior border of flap designed at level of inferior bony orbital rim. Anticipated standing
cutaneous deformity marked with horizontal lines. C, Flap in place. Interpolated paramedian forehead flap used to repair nasal
sidewall. D, E, Postoperative result. (From Tollefson TT, Murakami CS, Kriet JD: Cheek repair. Otolaryngol Clin North Am 34:640, 2001.)
A
B
C
D
E

560
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
and zygomatic cheek defects.18,19 Proximal portions of the
flap are de-epithelialized and tunneled subcutaneously
under the neck skin to reach facial defects. Advantages of
the flap include low donor site morbidity and the option
to reconstruct large, deep defects with cervical skin and
soft tissue without the need for free tissue transfer.
SUMMARY
The cheek, which has a broad, slightly convex surface, is
the largest facial aesthetic region, and the surgeon is
frequently required to reconstruct cutaneous defects in
this area. The cheek has a distinct anatomic configuration
that assists with reconstruction by local skin flaps. The
relative abundance of skin and subcutaneous fat of the
cheek provides multiple surgical options for repair of
cutaneous defects. A framework for selection of the
proper flap based on defect location and size is presented
to assist the reader in selecting the ideal method of repair.
superficial plane should be made as the muscle is encoun­
tered. Finding the muscle superiorly at its origin allows
the surgeon to define tissue planes with greater ease and
confidence. This maneuver is familiar to surgeons who
perform deep plane rhytidectomies.15,16
Neck and Cheek Defects
Advanced cutaneous malignant neoplasms of the cheek
that involve the parotid gland and neck often result in
large defects that require significant bulk for adequate
reconstruction. The supraclavicular artery island flap is a
pedicled fasciocutaneous flap useful to repair these
defects.17,18 The flap is based on the supraclavicular artery
as it arises from the transverse cervical artery (Fig. 20-31).
Intraoperatively, a Doppler signal confirms the location
of the artery in the triangular fossa bordered by the clav­
icle and the sternocleidomastoid and trapezius muscles.
The flap is then designed, reliably having dimensions of
up to 24 × 8 cm, with the ability to reach lateral, buccal,
FIGURE 20-30  ■  A-C, Full-thickness nasal defect of ala, tip, and sidewall with extension into medial cheek. D, Laterally based cheek
advancement flap incised along subciliary crease and advanced to nasofacial sulcus. Lateral aspect of flap secured to lateral orbital
rim periosteum to prevent lower lid retraction. Ipsilateral septal mucoperichondrial hinge flap reflected outward for lining of ala.
E, Defect repaired with cartilage grafts and paramedian forehead flap. Low hairline resulted in hair follicles transposed to distal
portion of flap. F, Postoperative result at 2 years. Postoperative laser therapy performed to eradicate hair follicles on nose. (From
Bhrany AD: Complex nasal reconstruction: a case study: reconstruction of a full-thickness nasal defect. Facial Plast Surg Clin North Am
19:183-195, 2011.)
A
B
C
D
E
F

20  RECONSTRUCTION OF THE CHEEK
561
FIGURE 20-31  ■  A, Squamous cell carcinoma involving ear, cheek, neck, and parotid gland. B, A 9 × 7-cm defect after resection, with
X identifying supraclavicular artery Doppler site and flap designed extending to shoulder. C, Flap elevated, proximal portion
de-epithelialized and tunneled under neck skin. D, Flap in place. E, Postoperative result at 4 months.
B
C
A
D
E

562
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
Local flap design is based on the orientation of RSTLs
in relationship to the cheek aesthetic units.
REFERENCES
1. La Trenta GS. Atlas of aesthetic face and neck surgery. Philadel­
phia: WB Saunders; 2004.
2. Janfaza P, Nadol JB, Galla RJ, et al. Surgical anatomy of the head
and neck. Philadelphia: Lippincott Williams & Wilkins; 2000.
3. Pierard GE, Lapiere CM. Microanatomy of the dermis in relation
to relaxed skin tension lines and Langer’s lines. Am J Dermatopa­
thol 1987;9:219.
4. Larrabee WF Jr, Sutton D. The biomechanics of advancement and
rotation flaps. Laryngoscope 1981;91:726.
5. Rustad TJ, Hartshorn DO, Clevens RA, et al. The subcutaneous
pedicle flap in melolabial reconstruction. Arch Otolaryngol Head
Neck Surg 1998;124:1163.
6. Jelks GW, Jelks EB. Prevention of ectropion in reconstruction of
facial defects. Clin Plast Surg 2001;28:297.
7. Menick FJ. Reconstruction of the cheek. Plast Reconstr Surg
2001;108:496.
8. Cook TA, Israel JM, Wang TD, et al. Cervical rotation flaps for
midface resurfacing. Arch Otolaryngol Head Neck Surg
1991;117:77.
9. Larrabee WF Jr, Trachy R, Sutton D, Cox K. Rhomboid flap
dynamics. Arch Otolaryngol 1981;107:755.
10. Lister GD, Gibson T. Closure of rhomboid skin defects: the flaps
of Limberg and Dufourmentel. Br J Plast Surg 1972;25:300.
11. Murakami CS, Nishioka GJ. Essential concepts in the design of
local skin flaps. Facial Plast Surg Clin North Am 1996;4:455.
12. Murakami CS, Odland PB. Bilobe flap variations. Oper Tech Oto­
laryngol Head Neck Surg 1993;4:76.
13. McGregor JC, Soutar DS. A critical assessment of the bilobed flap.
Br J Plast Surg 1981;34:197.
14. Zitelli JA. The bilobed flap for nasal reconstruction. Arch Derma­
tol 1989;125:957.
15. Mitz V, Peyronie M. The superficial musculo-aponeurotic system
(SMAS) in the parotid and cheek area. Plast Reconstr Surg
1976;58:80.
16. Coppini L, Zigiotti GL, Messerotti G, et al. The superficial
musculo-aponeurotic system (SMAS) of the face and neck. Anatomy
and surgical dissection. Acta Otorhinolaryngol Ital 1983;3:427.
17. Vinh VQ, Anh TV, Ogawa R, Kyakusoku H. Anatomical and clinical
studies of the supraclavicular flap: analysis of 103 flaps used to recon­
struct neck scar contractures. Plast Reconstr Surg 2009;123:1471.
18. Chiu ES, Li PH, Friedlander PL. Supraclavicular artery island flap
for head and neck oncologic reconstruction: indications, complica­
tions and outcomes. Plast Reconstr Surg 2009;124:115.
19. Chan JWH, Wong C, Ward K, et al. Three- and four-dimensional
computed tomographic angiography studies of the supraclavicular
artery island flap. Plast Reconstr Surg 2010;125:525.

563
C H A P T E R 2 1 
RECONSTRUCTION OF THE FOREHEAD
Ronald J. Siegle
INTRODUCTION
A paralyzed and ptotic eyebrow, an oblique midforehead
scar, focal alopecia in a brow, an asymmetric hairline—
for the skilled reconstructive surgeon, these deformi­
ties would be considered complications of forehead
re­construction. For the unskilled and unknowledgeable
surgeon, these are more likely to simply be written off
as common sequelae of reconstruction.
Reconstructive surgery of cutaneous defects of the
forehead may be simple or complex. Several goals must
be considered: preservation of motor function (temporal
branch of facial nerve) and, if possible, sensory nerve
function; maintenance of the aesthetic boundaries of the
forehead, including position and symmetry of the eye­
brows and the frontal and temporal hairlines; and optimal
scar camouflage by placement of scars in or adjacent to
the hairline, eyebrows, and relaxed skin tension lines
(RSTLs) whenever possible. This chapter reviews the
anatomy of the soft tissue cover of the forehead and
the principles of reconstruction of this aesthetic region
of the face. The reader is also referred to a number of
well-written review articles on forehead reconstruction,
from many of which this author has learned and thus
improved his expertise in reconstruction of this facial
region.1-7
ANATOMY
The skin of the forehead varies not only from person to
person but also changes notably with aging and exposure
to the sun. Beginning in the suprabrow area and moving
toward the anterior hairline, forehead skin dermal thick­
ness and sebaceous gland concentration decrease. This is
manifested by a decreasing skin thickness and a less porous,
less oily skin. In youth, the forehead skin is taut and
smooth, with a shiny appearance. In contrast, older or
sun-damaged skin has an increased mobility, a dull appear­
ance, and rhytids; although aesthetically compromising,
these features all facilitate reconstructive procedures.
The predominant muscle of the forehead aesthetic
region is the anterior belly of the occipitofrontalis muscle.
The vertical orientation of the skeletal muscle fibers is
responsible for the transversely oriented RSTLs. Often
quite prominent in younger individuals, the muscle thick­
ness diminishes substantially with age. Extensive cutting
of this muscle during reconstructive procedures may
cause local palsies that have a prolonged recovery. Also
of note is the often present anterior extension of the
galeal median raphe. This fascial extension in the mid­
forehead is devoid of muscle fibers and accounts for the
often excellent aesthetic result that is attainable with ver­
tical midline wound closures of the forehead. The other
muscles in the forehead region include the orbicularis
oculi, procerus, and corrugator supercilii. As a rule, tran­
section of portions of these muscles is without major
consequence.
The forehead is a richly vascularized region. It is sup­
plied centrally by the right and left supratrochlear and
supraorbital arteries and laterally by the anterior branch
of the temporal arteries. These vessels are located in the
subcutaneous tissue and are predictable in their location.
Transection of these vessels during the elevation of
random pattern cutaneous flaps should not be of any
major consequence because of the ample collateral circu­
lation of forehead skin.
Loss of nerve function, whether motor or sensory, has
great consequence to the patient. The motor nerve to the
frontalis muscle is the temporal branch of the seventh
cranial nerve (Fig. 21-1). This nerve innervates the entire
frontalis muscle and is most at risk for injury during flap
elevation, not on the forehead, but rather over the zygo­
matic arch and in the temporal area. The thin skin and
subcutaneous tissue in these areas cause the nerve to be
close to the skin surface, particularly in thin or aged
individuals. Development of flaps in the temporal region
may transect the nerve if the flap is not cautiously ele­
vated. On reaching the forehead, the nerve enters the
frontalis muscle from its deep surface, and inadvertent
transection of the nerve is much less likely. To prevent
motor nerve injury, dissection of local cutaneous flaps of
the forehead should be in the subcutaneous tissue plane
or below the frontalis muscle and above the periosteum
of the frontal bone.
The major sensory nerves of the forehead are the
supraorbital and supratrochlear nerves, which run with
their named arteries. After exiting their foramina in the
sub-brow area, they pierce the overlying muscle and
extend cephalad in the subcutaneous tissue. Transection
of these nerves yields anesthesia distal to the point of
injury. The anesthesia may extend posteriorly to the level
of the parietal scalp. The numbness perceived by the
patient is not only annoying but also potentially harmful
because of loss of normal sensory feedback. To prevent
sensory nerve damage in dissection of forehead cutaneous

564
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
On occasion, the surgeon is confronted with cutane­
ous defects of forehead skin in which the facial nerve
branch to the frontalis muscle has been cut, yielding a
ptotic eyebrow, facial asymmetry, and occasionally visual
field limitation on upward gaze. Not all individuals are
functionally compromised by a paralytic eyebrow ptosis.
If individuals wear eyeglasses, they may adequately cam­
ouflage the appearance of a ptosis with their eyeglasses
and the ptosis will not require surgical repair. However,
for those situations with functional or significant aes­
thetic alteration, several techniques are available to
elevate the eyebrow unilaterally. The author most com­
monly performs a direct eyebrow lift in which an ellipse
of skin is resected from the suprabrow area to elevate
the eyebrow approximately 4- to 8-mm higher than the
opposite eyebrow. The more lax the forehead skin,
the greater is the need to overcorrect the elevation. The
inferior border of the skin ellipse is incised along the
superior margin of the eyebrow parallel to the axis of
the hair shafts. Horizontal mattress suspension sutures
are placed between the sub-brow dermis and the forehead
periosteum. Nylon sutures (5-0 clear) are passed through
the periosteum approximately 1 cm above the desired
point of eyebrow elevation.
Repair of the skin incision then follows with a layered
closure, preferably by intracuticular suturing techniques.
A second alternative for correction of eyebrow ptosis is
flaps, it is essential that the surgeon carefully undermine
skin flaps in the superficial subcutaneous tissue plane. For
larger flaps developed below the muscle, consideration
should be given to placement of incisions peripheral to
the path taken by these nerves.
FUNCTIONAL AND AESTHETIC
CONSIDERATIONS
The first goal of forehead reconstruction is to maintain
motor and sensory nerve function. Knowledge of forehead
anatomy and proper flap design will help accomplish this
goal the majority of the time. In some instances, sensory
nerves will require transection, particularly in reconstruc­
tion of large skin defects, but this should be done only if
no other effective reconstructive alternative is available.
The surgeon should not burden the patient with a motor
or sensory nerve deficit in exchange for a less complex
reconstructive procedure that requires transection of
important motor or sensory nerves. The compromised
function of a nerve, particularly motor, should never be
considered a routine consequence of reconstruction of the
forehead. Regrowth of sensory nerves can be anticipated;
however, complete transection of the supratrochlear or
supraorbital nerve results in anesthesia of the distal fore­
head and scalp commonly lasting for 1 year or more.
FIGURE 21-1  ■  Pathway of temporal branch of seventh cranial nerve in relationship to subcutis, fascia, and muscle. Area C is at
highest risk for nerve injury because of proximity of nerve to overlying skin. SMAS, superficial musculoaponeurotic system.
A
B
C
Skin
Subcutaneous fat
Frontalis m.
VII n.
Skin
Skin
VII n.
VII n.
SMAS
SMAS
Temporalis m.
Temporoparietal
fascia
Temporalis
fascia

21  RECONSTRUCTION OF THE FOREHEAD
565
weeks after surgery is of no value if pathologic examina­
tion of the tissue excised shows that tumor is still present
in the margins of the resection. As a micrographic
surgeon, the author is fortunate to be able to remove skin
cancers with immediate feedback concerning tumor
margins and can ensure a tumor-free field before pro­
ceeding with reconstruction. There are other means to
achieve margin control, such as traditional frozen sec­
tions. In addition, reconstruction can be delayed for
several days until pathologic reports of permanently fixed
specimens are available. The important message is that
local tissue rearrangement in the form of cutaneous flaps
should not be performed until successful tumor removal
has been confirmed. Priorities in order of importance are
to remove tumor completely, to maintain function, and
to restore appearance.
The use of local anesthesia for surgery on the forehead
is usually well tolerated. The anesthetic that is used most
frequently is 1% lidocaine with 1 : 100,000 concentration
of epinephrine. Many surgeons add sodium bicarbonate
to this solution with a final concentration of 0.1 mEq/mL
to minimize the pain of injection. There are several addi­
tional steps that can be taken to minimize the discomfort
of infiltrative anesthesia. Complete forehead anesthesia
may result from bilateral regional nerve blocks. Anes­
thetic is injected bilaterally beneath the eyebrow along
the bony orbital rim from midline to a lateral point
approximately two-thirds of the length of the eyebrow.
Approximately 2 mL of anesthetic solution per side yields
an anesthetic field extending from the eyebrow cephali­
cally to the parietal scalp. Individual nerve blocks may be
accomplished by injection of the subcutaneous tissue
adjacent to the foramen of the supratrochlear or supra­
orbital nerve. Field blocks with injections placed just
proximal to the surgical site will often yield distal anes­
thesia within a minute and allow painless injection of the
remaining portion of the forehead. An important point
to remember is that local anesthetics affect motor nerves.
Thus, a lateral forehead nerve block may cause paralysis
of the frontalis muscle, which in the intraoperative setting
cannot be differentiated as to whether it is caused by
surgery or local anesthesia. This paresis may last several
hours, and therefore no corrective procedures for eyebrow
ptosis are indicated until the cause of the ptosis is known.
Options for repair of cutaneous forehead defects
include healing by secondary intention, primary wound
closure, skin graft, and local or, uncommonly, distant flap.
As a rule, the healing of the forehead by secondary inten­
tion, although adequate for midline defects, yields sub­
optimal scars elsewhere on the forehead. In addition to
the midline, extreme lateral forehead and temple sites
may heal beautifully by secondary intention.
Primary repairs of forehead defects are often possible.
There is great variability in the laxity and availability of
excess skin on the forehead. Redundant skin is more
likely in older individuals and those with sun-damaged
skin. Redundant forehead skin may be present in either
the horizontal or vertical axis. Skin redundancy can best
be determined by pinching and spreading of the forehead
skin. Deep forehead furrows may contain relatively large
amounts of redundant skin. If adjacent tissue is not
adequate for primary wound repair, options include
to perform a procedure similar to a direct eyebrow lift,
but incisions are made in the midforehead, thereby cam­
ouflaging the incisions in the horizontal creases of the
forehead skin. Coronal forehead lifts for correction of
unilateral eyebrow ptosis are not indicated.
In the last decade, the concept of facial aesthetic regions
has greatly simplified and, more important, improved the
outcome of facial reconstructive procedures. Facial aes­
thetic regions have borders that must be maintained to
ensure facial symmetry. As a rule, a given aesthetic region
is covered with skin that has identical or similar charac­
teristics throughout. If “neighborhood skin” within the
same aesthetic region can be recruited to repair a skin
defect, optimal aesthetic results may be obtained. The
forehead facial aesthetic region is defined peripherally by
the juncture lines with the frontal scalp superiorly, the
temporal scalp and temple laterally, and the eyebrows and
glabella inferiorly (Fig. 21-2). The forehead is somewhat
different from other facial aesthetic regions in that it has
both an actual and perceived boundary line. Hairstyling
can play a major role in forehead visibility. Bangs or a
sweeping hairstyle can be used to cover all or part of the
forehead. Thus, hairstyling may be used to camouflage a
large area of forehead scarring and disfigurement.
In planning reconstruction of a cutaneous forehead
defect, the surgeon must first ask what the aesthetic goals
are. The specific aesthetic goals for forehead reconstruc­
tion are maintenance of eyebrow symmetry; maintenance
of natural-appearing temporal and frontal hairlines; when
possible, positioning of scars adjacent to or in hairlines
and eyebrows; when possible, creation of transverse
rather than vertical scars (except in the midline); and
avoidance of diagonal scars.
RECONSTRUCTIVE PRINCIPLES
In cases of skin cancer of the forehead, a forehead flap
that is beautifully designed and has healed perfectly a few
FIGURE 21-2  ■  Forehead aesthetic region defined by junction
lines with frontal scalp superiorly, temporal scalp and temple
laterally, and eyebrows and glabella inferiorly. Reconstruction
of forehead skin defects is facilitated by dividing aesthetic
region into three units: midline (M), paramedian (P), and lateral
(LT). Sources of skin for construction of local flaps for repair of
forehead defects include local (L), glabella (G), and temple (T).

566
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
Rotation flaps are often useful for forehead recon­
struction because they take advantage of the curvature of
the frontal bone. They are usually designed as large flaps
and thus offer reliable vascularity to the flap. The major
disadvantage of a cutaneous forehead rotation flap is the
lengthy incision line required to create the flap, which is
often diagonal to the horizontal creases of the forehead.
Multiple designs of rotation flaps are possible, including
unilateral and bilateral. Bilateral rotation flaps often take
the form of an O-Z closure.
Transposition flaps, the most common flaps used to
repair cutaneous defects in other areas of the face, play a
lesser role in forehead reconstruction. They may be used
in the glabellar and lateral forehead areas but often create
suboptimal scars because the scars are frequently not
parallel to RSTLs. As a consequence of the need to close
the flap donor site, scars may be positioned in a less than
ideal orientation. Transposition flaps also frequently
cause a slight contour abnormality and are usually trans­
ferred under excess wound closure tension. The designs
most commonly used include the rhombic and the 30°
transposition flaps.
Conceptually dividing the aesthetic region of the fore­
head into three aesthetic units greatly simplifies the
thought process and decision-making used for flap selec­
tion. The forehead can topographically be divided into
the following units: midline; paramedian, extending over
the convexity of the forehead from midline to the mid­
pupillary line; and lateral forehead, extending from the
midpupillary line to the juncture with the temple
(see Fig. 21-2).
Midline Forehead Reconstruction
Midline or centrally located cutaneous defects of the
forehead can often be closed in a transverse orientation
if their vertical height is not too great. Although tissue
availability may be sufficient, the medial eyebrows, func­
tioning almost like a free margin, may be elevated to an
unacceptable height. For vertically oriented midline or
near-midline defects, primary wound closure oriented
with the long axis of the wound is often optimal (Fig.
21-3). The linear axis of the closure can be vertically
oriented with an expectant acceptable aesthetic result.
This approach takes advantage of the anterior extension
of the galea and the lack of midline frontalis muscle,
which probably accounts for the acceptable scar when
wound repair in this area is vertically oriented. Whether
primary wound closure is in a vertical or horizontal ori­
entation, advancement of wound margins causes the
development of standing cutaneous deformities. These
deformities may be excised by a W-plasty or M-plasty
when feasible (Figs. 21-4 and 21-5).
Vertically oriented primary wound closure of midline
cutaneous forehead defects allows extensive undermining
beneath the fascia of the frontalis muscle without com­
promise of motor or sensory nerve function. Although
wound closure in a vertical orientation often creates
unobtrusive scars, a noticeable drawback is the medial
displacement of both eyebrows. Depending on eyebrow
visibility, hair density, color, and aesthetic concerns of the
patient, medial displacement of the eyebrows may or may
borrowing skin from regional sites (including the temple,
scalp, and glabella) and use of skin grafts. Although skin
grafts are an easy method of repairing large defects of the
forehead, they usually yield suboptimal results because of
poor color and texture match with the remaining fore­
head skin. Split-thickness skin grafts are appropriate for
patients with skin cancer who are at high risk for recur­
rence. The skin graft facilitates accurate surveillance of
the tumor site.
FLAPS FOR FOREHEAD RECONSTRUCTION
Cutaneous and musculocutaneous flaps are an excellent
means to reconstruct forehead skin defects that cannot
be repaired primarily. Flaps can usually be harvested from
the forehead skin adjacent to the defect, thus maximizing
aesthetic outcome. Because there are a number of differ­
ent flaps that can be created, one can usually be designed
that offers limited impairment of function. When such
flaps are used, recovery is usually rapid and without
motor or sensory nerve deficit. In general, small flaps
should consist only of skin and subcutaneous tissue.
Undermining of the flap is carried out in the superficial
subcutaneous tissue plane. Although this maintains the
subdermal plexus, it creates more bleeding and is more
surgically challenging than dissection beneath the fron­
talis muscle because of the need to dissect around the
neurovascular bundles.
Musculocutaneous flaps are dissected beneath the
frontalis muscle and are required for repair of larger
defects and in situations in which a cutaneous forehead
flap might result in excess wound closure tension. Mus­
culocutaneous forehead flaps can be widely undermined
below the fascia of the frontalis muscle in a relatively
avascular tissue plane. Careful flap design is necessary to
prevent or to limit transection of sensory nerves. Under­
mining at this deep level may provide only limited tissue
for direct advancement because of the constraints of the
overlying fascia of the frontalis muscle. Musculocutane­
ous flaps, in contrast to cutaneous forehead flaps, involve
mobilization of tissue over a fixed infrastructure, specifi­
cally the frontal bone. Thus, for larger defects repaired
with musculocutaneous forehead flaps, there may be
moderate to extreme tension on the closure line. Despite
this, most flaps heal well because of their abundant
vascularity.
Advancement is the most common design of flaps used
for forehead reconstruction. Among the main benefits of
advancement flaps are maintaining a natural contour of
the forehead, facilitating optimal scar placement in hori­
zontal forehead creases, and usually providing an ade­
quate source of skin for reconstruction. The two major
disadvantages of advancement flaps are the requirement
for extensive undermining for larger flaps and the need
for multiple incisions. Multiple designs for advancement
flaps are possible, including unilateral, bilateral, subcuta­
neous tissue pedicle, and A-T and O-T repairs. Bilateral
advancement flaps often take the form of an H-plasty if
two parallel incisions are made to create the flaps. If
single incisions are used, repair assumes the form of a
T-plasty (see discussion in Chapter 6).

21  RECONSTRUCTION OF THE FOREHEAD
567
FIGURE 21-3  ■  A-D, Preoperative and 3.5-month postoperative views. A 3.5 × 4-cm cutaneous defect of central forehead repaired by
bilateral advancement of remaining forehead skin. Patient had previous right paramedian forehead flap to reconstruct nose. No
revision surgery performed. (Courtesy of Shan R. Baker, MD.)
A
B
C
D
not be acceptable and should be discussed with the patient
preoperatively. Medial displacement of the eyebrows is a
particular dilemma when the defect is in the glabella.
Smaller defects (≤2 cm) in this area of the forehead may
be repaired with V-Y subcutaneous tissue pedicled
advancement flaps recruiting skin from the central fore­
head immediately superior to the defect. This has the
great advantage of not distorting the relationship of the
medial eyebrows by maintaining their natural anatomic
position (Fig. 21-6).
Primary repair of large central forehead defects can be
facilitated by intraoperative expansion of scalp and fore­
head skin (Fig. 21-7). This technique has enabled the
author to recruit 1 to 2 cm of additional skin beyond that
achievable by wide undermining. A 30-mL Foley catheter
is tunneled beneath the frontalis muscle beyond the
supraorbital nerve to the lateral forehead and temple
regions. The balloon of the catheter is inflated until the
skin blanches and is maintained at that volume for 3
minutes and then decompressed for 3 minutes. This cycle
is repeated two additional times, with each expansion
yielding additional tissue stretch. The stretched tissue
gained with intraoperative expansion is often sufficient
to close midline defects, which otherwise could not be
repaired by primary approximation.
When intraoperative skin expansion does not provide
adequate tissue for primary repair, the use of bilateral
rotation flaps is an excellent method of reconstructing
sizable upper midforehead cutaneous defects (Fig. 21-8).
Flaps are designed so that they are based inferolaterally,
and incisions to create the flaps are positioned along the
anterior hairline whenever possible to assist with scar
camouflage. Repair of midline cutaneous defects with
rotation flaps may be accomplished by unilateral or bilat­
eral flaps. Bilateral flaps are best to maintain symmetry
because of some lowering of the hairline, which tends to
result from closure of the flap donor site. Large flaps
should be dissected in the subfascial plane and require
transection of sensory nerves extending peripheral to
incisions necessary to create the flap. This in turn results
in numbness of the anterior scalp. The patient should be
informed of this expected outcome preoperatively.

568
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 21-4  ■  A-C, Excision of forehead tumor and W-plasty designed to allow both midline wound closure and camouflage of scars
in glabellar creases.
C
A
B
FIGURE 21-5  ■  A, A 3 × 2.5-cm skin defect of central forehead. Primary wound closure planned. Inferior W-plasty and superior M-plasty
designed for excision of standing cutaneous deformities. B, Wound closed. Superior standing cutaneous deformity excised in straight
line instead of M-plasty. C, Postoperative result at 9 months. No revision surgery performed. (Courtesy of Shan R. Baker, MD.)
A
B
C

21  RECONSTRUCTION OF THE FOREHEAD
569
FIGURE 21-6  ■  A, A 2 × 2.2-cm cutaneous defect of glabella. V-Y subcutaneous tissue pedicled advancement flap designed for repair.
B, C, Flap incised and in place. This approach prevents medial displacement of eyebrows. D, E, Preoperative and 7-year postopera­
tive views. No revision surgery performed. (Courtesy of Shan R. Baker, MD.)
A
B
C
D
E
FIGURE 21-7  ■  A, A 5 × 4-cm skin defect. B, Planned tunnel marked extending below frontalis muscle and lateral to supraorbital nerve
(SO). Tunnel used to place intraoperative tissue expander for purpose of expanding skin of lateral forehead and temple. C, Foley
catheter in place and balloon expanded. D, One week after primary closure of defect with W-plasty.
A
B
C
D

570
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
oriented axis, the result is often excessive eyebrow eleva­
tion. Defects near the hairline closed in a horizontal
orientation have less propensity to elevate the eyebrow
compared with defects of similar size located more infe­
riorly in the proximity of the eyebrow (Fig. 21-10).
Eyebrow elevation caused by horizontally oriented
repair of cutaneous defects of the paramedian forehead
aesthetic unit may or may not be disfiguring and must be
assessed individually. Wound closure in patients with lax
and wrinkled forehead skin can result in eyebrow elevation
1 cm above the opposite side, and within several weeks
postoperatively, the effects of gravity return the elevated
eyebrow to a more symmetric position. In contrast, in a
younger individual, even a 3- or 4-mm eyebrow elevation
may persist because of the innate tissue elasticity. When
closure of a forehead defect is likely to cause excessive
eyebrow elevation, elevation can be limited by suturing the
dermis of the eyebrow and the underlying muscle to
the periosteum of the superior bony orbital rim. This has
the effect of limiting the upward migration of the eyebrow
during dissection and advancement of forehead skin.
Paramedian Forehead Reconstruction
The degree of bossing of an individual’s forehead is vari­
able, but as a rule, the area from the midline to the
midpupillary line tends to be convex. I have labeled this
area the paramedian forehead aesthetic unit (see Fig.
21-2). There are fewer good options for repair of cutane­
ous defects of this portion of the forehead compared with
the central part of the forehead. The RSTLs are hori­
zontal in the forehead, and they are the ideal location for
placement of incisions. When possible, primary wound
closure is best accomplished with a horizontally oriented
layered repair to allow maximal scar camouflage (Fig.
21-9). Horizontally oriented primary wound repair is
restricted by the vertical height of the defect and thus the
degree of eyebrow elevation resulting from wound
closure. Eyebrow elevation, in turn, is related to the
degree of forehead skin and scalp redundancy and mobil­
ity. Eyebrow elevation from horizontally oriented wound
repair is also influenced by the size and position of the
cutaneous defect. When large defects (more than 3 cm
in vertical height) are closed primarily in a horizontally
FIGURE 21-8  ■  Midline forehead defect closed with two rotation flaps. Incisions placed within frontal and temporal hairline.
C
A
B

21  RECONSTRUCTION OF THE FOREHEAD
571
For defects of the paramedian forehead aesthetic unit
near the anterior hairline, a bipedicle advancement flap
can be useful for repair (Fig. 21-11). An incision is made
in the hair-bearing scalp parallel to the superior border
of the defect and is carried full thickness through the
galea. The bipedicle flap is undermined in all directions
and advanced inferiorly to close the forehead defect. The
degree of inferior advancement of the flap is dependent
on the length of the scalp incision and the position of the
defect. The longer the releasing incision, the greater is
the mobility of the flap. The secondary defect created
behind the frontal hairline can usually be closed by addi­
tional undermining below the galea, posterior to the scalp
incision. The bipedicle advancement flap is well vascular­
ized and provides a hidden donor site scar but does result
in some lowering of the hairline. The larger the defect
in the vertical dimension, the greater will be the inferior
displacement of the anterior hairline and the greater will
be the difficulty in closing the donor site of the flap.
When skin defects of the paramedian forehead are too
large for primary repair or have a lengthy vertical com­
ponent, an advancement flap is usually the preferred
method of closure. Incisions are made horizontally,
extending laterally from the superior and inferior aspects
of the defect. The incisions are limited in length to create
a flap with an approximate 4 : 1 ratio of length to width
(Fig. 21-12). Most flaps, if they are not subjected to
significant wound closure tension, are dissected in the
superficial subcutaneous tissue plane. Dissection is in
the subdermal plane superficial to the neurovascular
bundles while avoiding excess thinning of the flap. The
borders of the defect are squared, and standing cutaneous
deformities are removed on either side of the flap’s base
(see Fig. 21-12). The deformities that develop from
FIGURE 21-9  ■  A, A 2.5 × 1.5-cm skin defect of paramedian aes­
thetic unit of forehead. Horizontally oriented primary wound
closure planned with W-plasties designed for excision of stand­
ing cutaneous deformities. B, Postoperative result at 6 months.
No revision surgery performed. (Courtesy of Shan R. Baker, MD.)
A
B
FIGURE 21-10  ■  A, A 3.5 × 2-cm cutaneous defect of paramedian forehead. B, C, Wound repaired primarily. D, Postoperative result at
5 years. Excessive elevation of eyebrow is not observed. (Courtesy of Shan R. Baker, MD.)
A
B
C
D

572
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 21-11  ■  A, Excision of upper forehead tumor. Incision to create bipedicle advancement flap is full thickness to periosteum
posterior to hairline and parallel to long axis of defect. B, C, Advancement of bipedicle flap and closure of defect. Donor defect
closed primarily after posterior scalp undermining.
A
B
C
advancement can be removed anywhere along the length
of the flap so that the scar resulting from excision can be
positioned, when possible, in natural skin creases. A par­
ticularly good location for placement of the excisions is
in glabellar creases (Fig. 21-13). Cutaneous flaps advanced
from the lateral forehead and temple skin, where tissue
elasticity is greater, may not require removal of standing
cutaneous deformities if the rule of halves is used to close
the donor site. In such instances, gathering of tissue
occurs along the longer border of the wound, and this is
remedied by adjustment of the level of suture placement
to essentially “sew out” the difference in length between
the long and short borders of the wound (see discussion
in Chapter 7). Despite this adjustment in suturing, a
significant step-off between the surfaces of the flap and
the adjacent forehead skin is usually present because of
the tautness of the flap. However, even at 1 week post­
operatively, this discrepancy is dramatically lessened. A
helpful maneuver to camouflage scars is to make the flap
slightly wider than necessary if there are nearby natural
skin creases in which to hide the incisions.
For larger paramedian forehead defects, bilateral
advancement flaps are useful for repair (Fig. 21-14).
Figure 21-15 demonstrates the use of two advancement
flaps to reconstruct a cutaneous forehead defect. Note
that residual skin immediately above the eyebrow is
removed to develop a laterally based flap with an inferior
incision positioned along the border of the eyebrow. The

21  RECONSTRUCTION OF THE FOREHEAD
573
FIGURE 21-12  ■  A, B, Forehead defect closed by unipedicle advancement flap from lateral forehead skin. Standing cutaneous deformi­
ties excised at base of flap.
A
B
lateral flap is typically longer than the medial flap because
of the increased elasticity of lateral forehead skin, which
facilitates a greater degree of advancement (Fig. 21-16).
Rectangular advancement flaps, whether single or bilat­
eral, are perfect for repair of paramedian forehead defects
because of their ability to mobilize adjacent skin, to mini­
mize vertical incisions, to use RSTLs for scar camouflage,
and to remove standing cutaneous deformities from a
lateral location often in or parallel to crow’s-feet wrinkles
(Fig. 21-17).
As in the median forehead, reconstruction of the para­
median forehead aesthetic unit can be facilitated by the
use of intraoperative tissue expansion. By expansion of
the skin of the lateral forehead and temple, enhanced
tissue mobility is achieved in a matter of minutes. This
often results in less wound closure tension than if expan­
sion were not used. The potential for vascular compro­
mise by acutely expanding forehead skin is theoretically
possible but not likely because expansion is accomplished
deep to the frontalis muscle, which may serve to protect
the skin from vascular injury. Intraoperative expansion
can also be performed immediately adjacent to the defect,
which will facilitate primary wound repair. Towel clamps
or sutures are often necessary to prevent extrusion of
the Foley catheter through the wound during tissue
expansion.

574
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 21-13  ■  A, A 3 × 3-cm paramedian lower forehead cutaneous defect in a 55-year-old man. Unilateral advancement flap marked
for wound closure. W-plasty within glabellar creases facilitates removal of standing cutaneous deformity. B, Postoperative result at
3 months. Scar camouflage achieved by placement of incisions in natural horizontal and vertical creases of forehead.
A
B
FIGURE 21-14  ■  A, A 1.5 × 1.5-cm cutaneous defect of forehead. Bilateral advancement flaps (H-plasty) designed for repair. Standing
cutaneous deformities marked for excision at base of designed flaps. B, C, Flaps dissected and apposed. Standing cutaneous defor­
mities excised. D, Postoperative result at 6 months. (Courtesy of Shan R. Baker, MD.)
A
B
C
D

21  RECONSTRUCTION OF THE FOREHEAD
575
FIGURE 21-15  ■  A, B, Tumor excised superior to eyebrow and closed with bilateral advancement flaps (H-plasty). Note additional
tissue resection below tumor to allow placement of inferior scar along border of eyebrow.
A
B

576
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 21-16  ■  A, A 1.5 × 1.4-cm cutaneous defect of forehead. Bilateral advancement flaps (H-plasty) designed for repair. Laterally
based flap designed longer than medially based flap because of greater skin elasticity laterally. B, Wound repaired. C, D, Preopera­
tive and 3-month postoperative views. (Courtesy of Shan R. Baker, MD.)
A
B
C
D
FIGURE 21-17  ■  A, A 1 × 1-cm melanoma in situ marked for excision. Bilateral advancement flaps (H-plasty) designed for wound repair
after excision. Anticipated standing cutaneous deformities (SCD) marked for excision. B, C, Flaps are dissected in subdermal plane.
D, Flaps apposed. Standing cutaneous deformities excised. E, F, Postoperative result at 3 months. (Courtesy of Shan R. Baker, MD.)
A
SCD removed here
Flaps dissected in subdermal plane
B
C
D
E
F
Most cutaneous defects of the paramedian forehead
can be repaired primarily in a horizontal orientation or
reconstructed with horizontally oriented unilateral or
bilateral advancement flaps. Attempts should be made to
avoid vertical, curvilinear, and oblique incisions because
they result in scars that are not in RSTLs. This means
that vertically oriented primary wound repair and the use
of rotation and transposition flaps are to be avoided as a
rule. However, these alternatives may be necessary when
adjacent scarring from past surgical procedures has
limited the ability to use horizontally oriented advance­
ment flaps (Fig. 21-18). Whenever possible, incisions
should be positioned in the hairline or along the border
of an eyebrow.

21  RECONSTRUCTION OF THE FOREHEAD
577
advancement, rotation, and transposition flaps are useful
for reconstruction of defects of the lateral forehead skin
when primary wound closure is not possible. Cutaneous
flaps are preferred to skin grafts and healing by secondary
intention. Flaps harvested from the lateral temple skin
have the potential for complications related to injury of
the temporal branch of the facial nerve. It is in this region
that the motor branch to the frontalis muscle is most
likely to be injured as the nerve runs in the superficial
fascia over the zygomatic arch. Dissection of flaps should
be in the subcutaneous tissue plane, superficial to the
temporoparietal fascia that conveys the nerve. Skin
undermining in this area must be performed bluntly and
with good visibility to minimize possible transection of
the nerve. Even in thin individuals, there is usually suf­
ficient subcutaneous tissue to allow a dissection in the
mid–subcutaneous tissue plane, preserving the subdermal
plexus and flap vascularity.
Reconstructive options for repair of skin defects of the
lateral forehead often include single or bilateral rectan­
gular advancement flaps. A variation of bilateral advance­
ment flaps effective for repair of skin defects immediately
adjacent to the eyebrow in the lateral and paramedian
forehead aesthetic units is the O-T or A-T repair. These
techniques are discussed in detail in Chapter 9. The tech­
nique consists of making horizontal incisions on opposite
Lateral Forehead Reconstruction
The lateral forehead aesthetic unit begins at the level of
the midpupillary line and extends to the lateral eyebrow,
where it joins with the skin of the temple (see Fig. 21-2).
Unique to this area is the transition in topography from
the convexity of the paramedian forehead to a flat lateral
forehead and then slightly concave temple. These surface
features along with greater elasticity of lateral forehead
and temple skin compared with central forehead skin
provide a greater number of reconstructive alternatives.
Primary wound closure is often possible with the orienta­
tion of the repair parallel to RSTLs (Fig. 21-19). On the
lateral forehead, the transverse forehead wrinkles become
curvilinear, arch downward, and present excellent loca­
tions for placement of incisions. Some individuals have
exaggerated transverse skin creases in this area, making
them even better for scar camouflage. If creases are not
apparent, the patient may better define the location of
creases by squinting and elevation of the eyebrow.
Primary wound closure of cutaneous defects located at
the junction of the lateral forehead and temple may be
oriented horizontally so that scars rest in the RSTLs of
the crow’s-feet wrinkles (Fig. 21-20).
Although the lateral eyebrow, lateral upper eyelid,
and temporal hairline offer some anatomic constraints,
FIGURE 21-18  ■  A, A 3 × 2.8-cm paramedian forehead skin
defect in a 55-year-old man. Planned incisions marked for
laterally and medially based advancement flaps with slight
curvilinear borders to parallel forehead creases. Although
flaps have some pivotal (rotation design) movement, majority
of tissue movement is by advancement. Size of defect and
limitations of skin elasticity necessitated modification in
design of advancement flaps. B, Flaps in place. C, Postopera­
tive result at 6 weeks.
A
B
C

FIGURE 21-19  ■  A, A 1 × 1-cm skin defect of lateral forehead.
Horizontally oriented primary wound closure planned with
W-plasties designed for excision of standing cutaneous defor­
mities. B, Postoperative result at 1 week. C, Postoperative
result at 4 months. No revision surgery performed. (Courtesy
of Shan R. Baker, MD.)
A
B
C
FIGURE 21-20  ■  A, A 4 × 3-cm
cutaneous defect of temple.
Primary wound repair planned.
B, Wound repaired. Standing
cutaneous deformities removed
parallel to crow’s-feet wrinkles.
C, D, Preoperative view showing
basal cell carcinoma of temple
and
1-month
postoperative
result. (Courtesy of Shan R. Baker,
MD.)
A
B
C
D

21  RECONSTRUCTION OF THE FOREHEAD
579
FIGURE 21-21  ■  A, B, A-T closure of lateral forehead defect with use of transverse forehead creases for scar camouflage.
A
B
sides of the base of the defect in RSTLs or along the
superior border of the eyebrow (Fig. 21-21). This tech­
nique uses two small modified advancement flaps and
allows scar camouflage of all but the central vertical
closure line. The advancement flaps are modified by
using only one incision to create each flap rather than
two incisions. Although the primary movement of the
flaps is by advancement, some limited pivotal movement
also occurs. Burow triangles can be resected adjacent to
the eyebrows, or standing cutaneous deformities may be
eliminated by the rule of halves.
Smaller (≤1.5 cm) cutaneous defects of the lateral
forehead skin can often be repaired with an A-T repair
with the use of only one flap and one incision (Figs. 21-22
and 21-23). A Burow triangle is removed at the lateral
aspect of the eyebrow or farther laterally in the crow’s-
feet. The single unilateral incision required to create the
flap provides exposure for flap elevation and also is suf­
ficient for flap advancement into the defect. When the
defect is located near the eyebrow, enlargement of the
wound to the border of the eyebrow allows camouflage
of the incision along the superior margin of the lateral
eyebrow.
Rotation flaps designed in a number of configurations
are often effective in reconstruction of lateral forehead
cutaneous defects. In particular, a unilateral rotation flap
based inferiorly and laterally and designed so that its
curvilinear incision is along the margins of the anterior
hairline is an excellent method to reconstruct sizable
lateral forehead skin defects that are in proximity to the
FIGURE 21-22  ■  Advancement flap for repair of lateral forehead skin defect adjacent to eyebrow. Standing cutaneous deformity at
base of advancement flap removed from lateral crow’s-feet.

580
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 21-23  ■  A, A 1.6 × 1.6-cm lateral forehead skin defect in a 37-year-old man. Advancement flap using single incision designed
for repair. Triangles denote locations where standing cutaneous deformity can be removed for maximum scar camouflage. B, Wound
closure hiding excision of Burow triangle in lateral eyebrow line and incision to create flap in curvilinear lateral forehead crease.
C, Postoperative result at 7 months.
A
B
C
hairline (Fig. 21-24). Skin excess on the long side of the
wound can be sewn out by the rule of halves, or an equal­
izing Burow triangle can be removed in the hair-bearing
skin, which provides excellent scar camouflage. If some
of the temporal hair tuft has been lost, the curvilinear
incision can be designed upward into the scalp as far as
necessary to advance hair into the reconstructed area.
The standing cutaneous deformity that forms medially
and inferiorly at the pivotal point can be excised some­
times by an M-plasty to prevent excision of portions of
the eyebrow or upper eyelid skin.
O-Z repair of a forehead defect consists of a combina­
tion of either two rotation flaps or one rotation flap and
one advancement flap. The two-flap technique is useful
for repair of defects of the lateral forehead skin. Use of
two opposing flaps reduces the size of the flaps necessary
for wound repair and recruits skin from two separate
areas of the forehead, thus minimizing wound closure
tension (Fig. 21-25). The oblique scar that results from
wound repair may be acceptable in individuals who have
prominent curvature to their lateral forehead creases. In
contrast, this method of wound repair is less desirable for
forehead defects of the paramedian aesthetic unit because
the horizontal creases in this region of the forehead tend
not to be curvilinear.
Transposition flaps are commonly used to reconstruct
skin defects of the lateral forehead region, taking advan­
tage of the relatively lax skin of the temple. A number of
flap designs may be used, including 60° or 30° angled
flaps (Fig. 21-26) based superiorly or inferiorly and two
transposition flaps of similar or different angles partici­
pating in shared wound closure (Fig. 21-27). The scars
that result from multiple angulated incisions tend not to
be noticeable on the concave surface of the lateral fore­
head. Although transposition flaps in general are not
usually indicated for repair of most forehead cutaneous
defects, such flaps can be useful in transferring the entire
remaining aesthetic unit of the forehead, especially in the
case of the lateral aesthetic unit. An example is shown in
Figure 21-28, in which the remaining lateral aesthetic
unit was transposed inferiorly to repair a 6 × 5-cm skin
defect of the inferior lateral forehead skin and eyebrow.
Incisions for the flap were made along the anterior
temporal hairline. The donor defect, located at the hair­
line, was repaired with a single large rotation scalp flap,
which enabled a reasonable restoration of the temporal

21  RECONSTRUCTION OF THE FOREHEAD
581
FIGURE 21-24  ■  A, A 2.4 × 2.1-cm superior lateral forehead skin defect in a 42-year-old man. B, Design of inferiorly based rotation
flap with triangular or W-plasty excision of standing cutaneous deformity. C, Wound closed.
A
B
C
FIGURE 21-25  ■  A, B, Lateral forehead defect repaired with lateral rotation and medial advancement flaps. Portion of scar resulting
from wound repair has oblique orientation.
A
B

582
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 21-26  ■  A, A 1.3 × 1.2-cm skin defect. The 60° transposition flap designed for repair. Anticipated standing cutaneous deformity
(SCD) marked for excision along superior border of eyebrow. B, Wound repaired. C, Postoperative result at 5 months. (Courtesy of
Shan R. Baker, MD.)
A
SCD
removed here
Note flap
B
C
FIGURE 21-27  ■  A, A 2.5 × 2.1-cm lateral forehead skin defect in a 74-year-old man. Two alternative rhombic transposition flaps
designed for repair. B, Same defect with 30° angled transposition flap and M-plasty designed. C, Closure accomplished with 30°
angled transposition flap. D, Postoperative result at 3 weeks.
A
B
C
D
hairline and complete closure of the donor site of the
transposition flap.
EYEBROW RECONSTRUCTION
The challenges of eyebrow reconstruction are obvious.
The goals are to maintain an acceptable position and
continuity of the eyebrow. Reconstructive considerations
may vary somewhat between men and women because
women can pencil in the eyebrow with makeup, eliminat­
ing the need for what otherwise might require a complex
reconstruction. Small tumors can often be resected from
the eyebrow and layered primary wound closure per­
formed in a vertical orientation, maintaining eyebrow
continuity. Horizontal closure of eyebrow wounds results
in a reduction of the width of the eyebrow, which often
is quite noticeable and is not recommended. With verti­
cally oriented primary wound closure, extension of the
repair above and below the eyebrow results in scars
that are perpendicular to RSTLs and may produce sub­
optimal results. This can be prevented by repair of
intrabrow defects with bilateral rectangular advancement
flaps (H-plasty) similar to those described for defects

21  RECONSTRUCTION OF THE FOREHEAD
583
A
B
elsewhere on the forehead. The upper and lower inci­
sions to create the flaps are hidden along the inferior and
superior eyebrow margins (Figs. 21-29 and 21-30). Inci­
sions for unilateral or bilateral advancement flaps incor­
porating segments of the eyebrow must be made parallel
to the hair shafts (see Fig. 21-29A). This will minimize
transection of hair bulbs and subsequent problems with
either alopecia or ingrown hairs. Small to medium
(<3 cm) cutaneous defects of the eyebrow that extend
superiorly to the forehead skin and inferiorly to the upper
eyelid skin are best repaired primarily by bilateral
advancement or with a T-plasty closure (Fig. 21-31).
LARGE CUTANEOUS DEFECTS
Cutaneous defects of the forehead that are too large to
close with local flaps may be repaired with a full-thickness
skin graft as a preliminary step toward reconstruction.
After complete healing of the skin graft, prolonged tissue
expansion of the forehead skin adjacent to the graft can
be performed in anticipation of removal of the skin graft
and repair of the resulting skin defect with an expanded
advancement flap. This technique is discussed in detail in
Chapter 25. Another alternative is to perform serial exci­
sions of the skin graft with primary wound closure
to repair the cutaneous defect left by excising a portion
of the skin graft. This requires wide undermining of
the entire forehead skin in the subgaleal plane. Sizable
cutaneous defects of the forehead can be repaired in
this fashion without the use of a permanent skin graft.
Depending on the size of the skin defect, two or three
serial excisions of the skin graft and advancement of adja­
cent forehead skin are required. These procedures are
performed at 4- to 6-month intervals (Fig. 21-32).
COMPLICATIONS
All of the common complications of cutaneous surgery
exist for reconstruction of skin defects of the forehead.
Some complications occur more frequently in this region.
Wound closures on the forehead are almost always tighter
than those on other areas of the face because of the fixed
bony infrastructure and the relative inelasticity of fore­
head skin. Thus, pallor or a light blue cyanosis of the skin
of the flaps is observed in the early postoperative period
more commonly than is noted elsewhere on the face.
There is no single factor to determine how high wound
closure tension can be and still ensure skin viability.
The surgeon must balance patient variables, such as a
history of smoking or diabetes, with personal surgical
experience to decide when excessive wound closure
tension is present. The consequence of misjudgment is a
compromised blood supply to the skin with either super­
ficial epidermal or deeper dermal tissue loss. As a rule,
these complications are uncommon, particularly when
large flaps are designed in an effort to mobilize adequate
FIGURE 21-28  ■  A, B, A 6 × 5-cm full-thickness skin and muscle defect of lateral forehead and temple.
Continued

584
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
C
D
E
F
C, Full-thickness transposition flap designed to repair defect. Incision for flap made along anterior hairline.
D, Large rotation scalp flap used to close donor defect of transposition flap. E, F, Postoperative result at 9 months. No revision
surgery performed. (Courtesy of Shan R. Baker, MD.)
FIGURE 21-28, cont’d  ■
forehead skin. However, many flaps used for forehead
reconstruction of cutaneous defects are elevated in the
subcutaneous tissue plane, which increases the potential
for bleeding and impaired vascularity. Inspection and
then reinspection to ensure a dry field are indicated
before wound closure. Despite the reduced vascularity of
some flaps and the potential for bleeding, wound infec­
tion is not more frequent for repair of skin defects of the
forehead compared with other sites on the face.
Alopecia of the eyebrow or scalp hair can result from
two causes. The first is improper angulation of incisions
causing transection of the hair bulbs during flap eleva­
tion. The second is undermining of hair-bearing skin in
a plane that is too superficial. This results in injury of
the hair bulbs and subsequent alopecia. Neither of these
problems should occur when surgeries are conducted by
experienced surgeons. Ingrown hairs are often observed
after reconstruction of the scalp and, to a lesser degree,
of the eyebrow. Despite proper surgical technique, the
healing wound and resultant scar may entrap hairs along
the incision line and cause both ingrown hairs and milia.
Sutures placed by chance into follicular structures may

21  RECONSTRUCTION OF THE FOREHEAD
585
FIGURE 21-29  ■  A, B, Bilateral advancement flaps used to repair intrabrow defect. Inset, Proper orientation of incisions parallel to hair
shafts to prevent injury to hair bulbs.
A
B
FIGURE 21-30  ■  A, A 1.2-cm medial eyebrow defect in a 62-year-old man. Laterally based advancement flap designed for repair.
B, Flap in place. C, Postoperative result at 2 weeks.
A
B
C

586
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 21-31  ■  A, A 2 × 2-cm cutaneous defect of eyebrow extending to forehead and upper eyelid skin. A-T plasty designed for
repair. B, Wound repaired. C-F, Preoperative and 1-year postoperative views. No revision surgery performed. (Courtesy of Shan R.
Baker, MD.)
A
B
C
D
E
F
also lead to the formation of sinus tracks with small cysts
in the incision line.
Edema is an expected consequence of any cutaneous
surgery. However, on the forehead, the tautness of repairs
in combination with the immobile bone beneath the skin
reduces the degree of swelling that can be experienced
elsewhere on the face. However, it is routine for edema
and bruising to appear in the periorbital region 1 to 3
days postoperatively. These consequences are often of
great concern to patients, and they should be informed
of the anticipated swelling and bruising to minimize
anxieties.
An important complication of forehead reconstruc­
tion is injury to the supratrochlear and supraorbital
sensory nerves. The resultant anesthesia is not limited to
a small area but rather extends for several centimeters
toward the top of the scalp. These nerves should be
spared whenever possible. Another serious complication
is injury of the temporal branch of the facial nerve. Tran­
section of the nerve will cause a permanent paralysis of
the eyebrow. On occasion, the nerve may be traumatized
during dissection but not actually transected. In such
situations, prolonged temporary paralysis or paresis may
be present for 3 to 6 months postoperatively. Nerve con­
duction and electromyographic studies may be helpful in
ascertaining the type and severity of nerve injury. In
cases of permanent paralysis, eyebrow-elevating proce­
dures can return symmetry to the eyebrows, in most
cases leaving only the adynamic forehead as a mark of
the paralyzed forehead.
SUMMARY
Reconstruction of cutaneous defects of the forehead is
not just a matter of wound closure. The reconstructive
surgeon must maintain or reestablish the normal aes­
thetic boundaries of the region while preserving motor
and sensory nerve function and maximally camouflaging
surgical scars. The surgeon must have a thorough knowl­
edge of the anatomy and function of this region of the
face and must understand the principles of soft tissue

21  RECONSTRUCTION OF THE FOREHEAD
587
FIGURE 21-32  ■  A, A 6 × 7-cm cutaneous defect of forehead and upper eyelid. B, First-stage reconstruction consisted of full-thickness
skin graft of upper eyelid defect and partial closure of forehead wound by bilateral advancement of wound margins. Gauze stent
secures skin graft in place. C, Six-month result after first surgical stage. D, Immediately after second surgical stage in which skin
graft and forehead scar were excised and the wound was repaired primarily by advancement of wound margins. E, Six months
after second surgical stage. (Courtesy of Shan R. Baker, MD.)
A
B
C
D
E
transfer and movement so that the optimum reconstruc­
tive procedure is selected.
REFERENCES
1. Dzubow LM. Forehead. In: Dzubow LM, editor. Facial flaps: bio­
mechanics and regional application. Norwalk, Conn: Appleton &
Lange; 1990.
2. Jackson IT. Forehead reconstruction. In: Jackson IT, editor. Local
flaps in head and neck reconstruction. St. Louis: CV Mosby; 1985.
3. Salasche SJ, Berstein G, Senkarik M. Forehead and temple. In:
Salasche SJ, Bernstein M, editors. Surgical anatomy of the skin.
Norwalk, Conn: Appleton & Lange; 1988.
4. Siegle RJ. Forehead reconstruction. J Dermatol Surg Oncol 1991;
17:200.
5. Tromovitch TA, Stegman SJ, Glogau RG. Forehead. In: Tromovitch
TA, Stegman SJ, Glogau RG, editors. Flaps and grafts of dermato­
logic surgery. Chicago: Mosby–Year Book; 1989.
6. Greenbaum SS, Greenbaum GH. Intraoperative tissue expansion
using a Foley catheter following excision of a basal cell carcinoma.
J Dermatol Surg Oncol 1990;16:45.
7. Zitelli JA. Wound healing by secondary intention: a cosmetic
appraisal. J Dermatol Surg Oncol 1990;16:401.

588
C H A P T E R 2 2 
RECONSTRUCTION OF THE AURICLE
Tessa A. Hadlock  •  Mack L. Cheney  •  Vito C. Quatela
INTRODUCTION
Reconstruction of the auricle presents a significant recon­
structive challenge, the ultimate goal of which is to
achieve as normal an appearance and position of the
auricle as possible. The orientation, size, and shape of the
reconstructed ear should closely approximate the oppo­
site ear. The postauricular sulcus should be preserved,
and the relationship of the postauricular skin to the scalp
should be maintained. The ear has an unusually high
ratio of cartilage to skin surface area. This fact, coupled
with the intricate three-dimensional features of the
auricle and its subtle topographic details, adds to the
complexity of any reconstructive effort.
Many defects involve both the skin and underlying
cartilage. Auricular reconstruction requires thin, well-
vascularized skin flaps. Poorly vascularized, noncompli­
ant skin, such as that found in the scar tissue that forms
during healing by secondary intention, is suboptimal for
reconstruction as it decreases the likelihood of achieving
an adequate final three-dimensional structure. After
oncologic surgery, surgical plans are influenced by the
location and size of the ablative defect, the vascularity of
the portion of the auricle adjacent to the defect, and the
extent to which the field has been exposed to radiation
therapy.
In planning of auricular reconstruction, anatomic
landmarks including the vermilion border, eyebrow, and
nasal alar margin are considered. These structures offer
only modest resistance to distortion from wound closure
tension created by surgical procedures in adjacent soft
tissue sites, such as the periauricular area. Auricular car­
tilage is supple and may not adequately resist distortion
secondary to scar contracture. Moreover, healing forces
tend to distort the ear if meticulous attention is not
directed toward a method of wound repair that minimizes
wound closure tension.
The presence of an adjacent hair-bearing scalp must
be considered. When possible, it is preferable to avoid
placing hair-bearing skin over the auricle. Ordinarily, the
hairline above the site of the planned reconstruction is
high enough not to interfere with accurate positioning of
the ear. However, proper positioning of the reconstructed
segment of the ear occasionally requires the use of hair-
bearing skin. In these cases, the hair can be permanently
eliminated later by depilation techniques.
When auricular reconstruction is poorly planned or
executed, the endeavor will be frustrating and disappoint­
ing. In such instances, a cascade of poor results follow
multiple revision surgeries, increased scar tissue, and
decreased skin vascularity at each stage. However, with
adherence to well-established reconstructive surgery
principles, the results of auricular reconstruction can be
extremely rewarding.
ANATOMY AND EMBRYOLOGY
The ear is morphologically unique. The skin of the lateral
surface is densely adherent to the perichondrium and is
devoid of subcutaneous tissue. The fascial layer between
the skin and perichondrium contains a subdermal plexus
of vessels. The medial surface of the ear has loosely
attached skin containing subcutaneous fat. As a result,
skin is relatively more abundant on the medial surface
compared with the lateral surface of the ear and has
greater mobility. Medial auricular skin provides an excel­
lent donor site for grafts and flaps. The skeletal compo­
nent of the ear consists of elastic cartilage. The unique
property of this cartilage, flexible and yet able to maintain
a complex topographic contour, distinguishes it from the
more rigid cartilage of the nasal septum or rib. Conse­
quently, reconstruction of the ear with rib or septal car­
tilage results in loss of flexibility of the reconstructed
auricle.
Topographic landmarks of the auricle are illustrated in
Figure 22-1. The cartilaginous framework is composed
of several distinct three-dimensional components. Medi­
ally, these components are the conchal, antihelical, anti­
tragal, helical, and lobular complexes.1 These units are
critical in planning the reconstruction of defects involv­
ing cartilage replacement.2
The arterial supply to the auricle is derived from
branches of the superficial temporal artery and the post­
auricular artery. Both vessels arise from the external
carotid artery.3 The medial surface of the ear is supplied
by the postauricular artery. The lateral surface is supplied
by both the postauricular and superficial temporal
arteries, creating two arterial networks.4 The triangular
fossa—scapha network is supplied by the helical branch
of the superficial temporal artery. The conchal network
is supplied by the postauricular artery, which provides
septal perforators to the conchal floor (Fig. 22-2). Flap
planning and design should give due consideration to
these arterial networks. Venous drainage is through
the postauricular vein, which drains into the external
jugular system. There is supplemental venous drainage
from the superficial temporal and retromandibular veins.

22  RECONSTRUCTION OF THE AURICLE
589
Triangular fossa
Spine of helix
Root of
helical crus
Tragus
Lamina tragi
Cavum of concha
Fissura of
antitragus
Cauda helicis
Antihelix
Cymba of
concha
Helix
A
Helix
Cauda helicis
Antihelix
Scapha
Posterior crus
Eminence of
fossa triangularis
Transverse sulcus
of anterior crus
Eminence of
cymba conchae
Ponticulus
Antitragus
Eminence of cavum conchae
B
FIGURE 22-1  ■  Auricular cartilage anatomy. A, Lateral aspect.
B, Medial aspect. C, Topographic landmarks of the lateral
surface of auricle.
Lobule
Triangular fossa
Cymba of concha
External auditory
meatus
Tragus
Cavum of concha
Helix
Antihelix
Scapha
Antitragus
Posterior crus
of antihelix
Anterior crus
of antihelix
C
Lymphatic drainage of the auricle is primarily to the
preauricular, infra-auricular, and mastoid lymph nodes.
The auricle is innervated by contributions from both
cranial and spinal nerves. They include the great auricu­
lar nerve (C2, C3), the auriculotemporal nerve (V3), the
lesser occipital nerve (C2, C3), and a branch of the vagus
nerve (X, Arnold’s nerve) (Fig. 22-3). The great auricular
nerve divides into an anterior and posterior branch. The
anterior branch supplies the lower half of the lateral
aspect of the auricle. The posterior branch supplies a
similar area on the medial surface of the auricle. The
auriculotemporal nerve supplies the superolateral surface
of the auricle. The lesser occipital nerve supplies the
superior aspect of the ear on the medial side. The concha
is supplied by Arnold’s nerve.
The auricle arises embryologically from the first and
second branchial arches.5 Hillocks appear in these arches
during the sixth week of gestation. The anterior hillock
gives rise to the tragus, the root of the helix, and the
superior helix; the posterior hillock becomes the antihe­
lix, tragus, and lobule. The first branchial groove forms
the external auditory meatus and concha.

590
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 22-2  ■  Arterial blood supply to auricle. A, Lateral aspect. B, Medial aspect. C, Lateral aspect of auricle, with indicated zones
supplied by superficial temporal and postauricular vascular systems.

To root of
helix branch
Superficial
temporal a.
Posterior auricular a.
Perforators from
posterior auricular a.
Auricularis
posterior muscle
Posterior
auricular a.
Superficial
temporal a.
Posterior
auricular a.
A
B
C

22  RECONSTRUCTION OF THE AURICLE
591
AURICULAR ARCHITECTURE
Analysis of the dimensions and proportions of the
external ear is important for planning reconstructive
procedures.6-9 The vertical height of the ear roughly
matches the distance between the lateral orbital rim and
the root of the helix, at the level of the eyebrow. Ear
width is approximately 55% of its length (Fig. 22-4), and
the helical rim protrudes 1- to 2.5-cm from the skull. The
angle of protrusion from the skull typically ranges from
25° to 30°. The vertical axis of the ear is inclined poste­
riorly at an angle of approximately 15° to 20°.10,11 The
original anatomic descriptions of auricular orientation
suggested that the long axis of the ear was roughly paral­
lel to the dorsum of the nose, but it is now widely recog­
nized that the ear is rotated 10° anterior to that plane.
The superior level of the ear matches the level of the
lateral eyebrow. To account for individual variations in
topographic features, positioning, and symmetry, the
contralateral ear is used as a template in planning recon­
struction, rather than strict adherence to textbook-
defined norms. The most important principle of auricular
reconstruction is that size, location, and orientation of
the reconstructed ear be similar to the normal ear. The
dominant features that make an ear recognizable are the
helix, tragus, antitragus, and conchal bowl.8,9
GENERAL PRINCIPLES
Auricular defects may be divided into defects of cutane­
ous coverage, with or without intact cartilage, and
defects that are full thickness. Small cutaneous defects
of the helical rim may be reconstructed with primary
wound closure and occasionally require small excisions
FIGURE 22-3  ■  Sensory innervation of auricle. A, Lateral aspect. B, Medial aspect.
Great auricular n.
Mastoid
branch
Auriculo-
temporal n.
Arnold’s n.
Lesser
auricular n.
Lesser
auricular n.
Great auricular n.
Mastoid
branch
A
B
FIGURE 22-4  ■  Proportions and orientation of normal auricle.

592
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
of cartilage to avoid distortion. Defects of the densely
adherent lateral auricular skin can rarely be closed pri­
marily, whereas those of the more pliable medial surface
can often be repaired primarily. The pliability of medial
auricular skin permits the harvest of relatively large
postauricular skin grafts with primary closure of the
donor site. Lateral cutaneous defects that have intact
cartilage are best treated with skin grafts, provided there
is intact perichondrium over the exposed cartilage. The
contralateral postauricular skin is an excellent donor
site for a full-thickness skin graft used to resurface
the lateral ear. Preauricular skin may also be used with
minimal donor site morbidity. In cases in which the
perichondrium is absent, resulting in an avascular
surface, cartilage may be removed if it is not critical to
auricular shape (see examples in Chapter 15). Windows
created through the cartilage provide surface contact
between the graft and the vascularized subcutaneous
tissue of the medial aspect of the auricle. The cartilage
of the concha, fossa triangularis, and scapha are ame­
nable to partial removal without loss of structural integ­
rity of the ear. The cartilaginous windows provide access
to the perichondrium of the medial aspect of the ear,
which in turn provides sufficient vascularity for success­
ful skin grafting.
Surgical approaches for reconstruction of defects of
skin and underlying cartilage include converting the
defect into a full-thickness wedge-shaped excision, fol­
lowed by primary wound closure, and employing a com­
posite graft or flap that incorporates structural support.
The size and location of the defect dictate which alterna­
tive is most appropriate. Defects less than 1.5 cm of the
helix or antihelix are best repaired by conversion to a
wedge-shaped excision. The wound is then repaired pri­
marily and results in a minimally visible scar. Whereas
this approach does reduce vertical height of the ear, the
difference with the contralateral ear is usually not con­
spicuous. When a wedge-shaped excision of the auricle
is performed, excessive wound closure tension is avoided
by removing a portion of the concha to accommodate
advancement of the two borders of the ear defect. If this
is not performed, cupping and distortion of the ear will
occur. Medium-sized helical defects, from 1.5- to 2-cm,
can be managed by composite grafting from the contra­
lateral ear.12 Typically, a composite graft half the size of
the defect is transplanted from the opposite ear, thereby
creating two ears of equal size (Fig. 22-5). The cartilage
edges of the graft and the recipient site are securely
approximated with a row of interrupted sutures. Graft
immobilization is essential for proper healing and can be
accomplished by use of bolster sutures to secure a splint
over the ear. De-epithelialization of the medial aspect of
the composite graft and its implantation into a subcuta­
neous recipient site have been described. The graft is
released from its soft tissue attachment in a second surgi­
cal stage. This approach is designed to increase graft
survival. Transfer of a composite graft from the contra­
lateral ear exposes both ears to some risk of infection and
deformity, so its use must be carefully considered in view
of this risk.
Many local flaps have been described for repair of
full-thickness auricular defects.13-22 Chondrocutaneous
composite advancement flaps are best suited to repair of
full-thickness helical rim defects. Helical chondrocutane­
ous composite flaps take advantage of the available tissue
of the remaining helical rim and the redundant lax skin
of the lobule. Anteriorly, a V-Y advancement of the
helical root designed as an island flap is usually combined
with a posterior chondrocutaneous composite advance­
ment flap to achieve closure of helical rim defects
(Fig. 22-6). Chondrocutaneous composite flaps may be
advanced with the medial skin intact or incised. Although
Antia originally described keeping the medial skin intact,
there is greater ease of flap advancement with at least a
limited incision of the medial skin. The arterial network
of the helix-scapha region allows the creation of long
chondrocutaneous composite flaps on a narrow pedicle.
Depending on the size of the helical defect, Burow tri­
angles are excised to facilitate advancement of the flaps
(Figs. 22-7 and 22-8).23 Chondrocutaneous flaps in the
form of transposition flaps may also be used for recon­
struction of nonhelical defects.
Both postauricular skin and preauricular skin serve as
ideal donor sites for the creation of interpolated tube
flaps. These flaps are used to reconstruct longer segments
of the helical rim that are too large for reconstruction
with a chondrocutaneous advancement flap. Initially, the
flap is dissected as a bipedicled flap that is tubed on itself
(Fig. 22-9A). After 3 weeks, one end of the cutaneous
tube is detached from its origin and secured to one border
of the helical rim defect. Three weeks later, the other end
of the tube is incised and inset in the other border of the
helical defect. Interpolated tube flaps are most useful for
reconstruction of defects confined to the helical rim that
are more than 2.5 cm in length (Fig. 22-10E, F).
Postauricular island advancement flaps work well for
conchal reconstruction and repair of full-thickness defects
of the nonhelical portions of the ear.24,25 The postauricu­
lar flap is based on the auricular branch of the postauricu­
lar artery. The flap is designed as an island based on
a subcutaneous tissue pedicle. A significant advantage is
that it provides a single-stage repair with easy closure of
the postauricular donor site. When it is designed as an
island, the flap is outlined and incised deeply through the
postauricular muscle. Posteriorly, the mastoid perios­
teum is incised, and the dissection proceeds in a superior
and anterior direction. Care is taken to preserve the vas­
cular supply to the flap as it enters the flap inferiorly.
With the subcutaneous pedicle intact, the flap is advanced
into its respective conchal or nonmarginal auricular
defect (Fig. 22-11). Postauricular flaps may also be devel­
oped as interpolated flaps, requiring a subsequent stage
to inset the flap. Interpolated postauricular flaps have
been described as a single-stage procedure, which is
accomplished by de-epithelialization of the skin of the
flap’s pedicle.15,24 A modification has also been described
that consists of harvesting of the flap from the medial
surface of the auricle to repair a skin defect of the lateral
surface. The technique requires de-epithelialization of a
portion of the pedicle.16
The principles set forth by Tanzer and colleagues for
microtia reconstruction are germane to reconstruction of
large acquired auricular defects.26,27 A three-dimensional
autologous rib cartilage framework and soft tissue

22  RECONSTRUCTION OF THE AURICLE
593
A
B
C
D
FIGURE 22-5  ■  Left congenital auricular deformity with more than 20-mm difference in vertical height between auricles. A, Preopera­
tive view. B, Donor ear composite graft outlined (half size of recipient deficit height). C, Preoperative view of affected ear. D, Harvested
composite graft.
Continued

594
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
E
F
E, Graft in place. Vertical height increased by 1 cm. Epithelium removed from medial aspect of graft, and medial
aspect implanted in subcutaneous pocket. F, Postoperative result at 12 months.
FIGURE 22-5, cont’d  ■
coverage are the mainstays of microtia repair. Similar
structural frameworks may be used for reconstruction of
large full-thickness auricular defects. Success depends on
the use of supple, thin, and highly vascular skin flaps to
cover cartilage grafts and to ensure refined contour of the
reconstructed ear. When local skin is scarred or absent,
as is often the case with acquired defects, a temporopari­
etal fascia flap may provide the necessary thin, highly
vascular covering for cartilage grafts and concomitantly
serve as a recipient site for overlying split- or full-
thickness skin grafting. When the vertical height of the
ear is likely to diminish by more than 20 mm by use of a
local flap, repair with a regional flap is more appropriate.
The temporoparietal fascia flap, combined with autolo­
gous cartilage grafting to replace auricular framework
deficiencies, has proved to be the most versatile regional
flap for reconstruction of larger full-thickness ear defects.
AURICULAR RECONSTRUCTION BASED ON
ANATOMIC LOCATION
In planning auricular reconstruction, one must consider
each missing component of the ear. A logical approach
to a discussion of reconstructing acquired auricular
defects is to divide them into those consisting of skin,
skin and cartilage, and full thickness. Such a discussion
is also best presented according to anatomic location
because of the variable availability of local and regional
tissue in each of these locations.
Defects of Conchal Bowl and Root of Helix
Conchal bowl defects may be allowed to heal by second­
ary intention, which usually results in minimal or no
auricular distortion. In subtotal conchal bowl defects,
full-thickness skin grafts provide adequate aesthetic
results and permit easy postoperative monitoring of the
area after extirpation of a cutaneous malignant neoplasm
(Fig. 22-12). If exposed cartilage is devoid of perichon­
drium, it can be safely resected because conchal cartilage
is not necessary for auricular form. The medial auricular
skin becomes the nutrient bed for the skin graft. Graft
immobilization is achieved with a bolster dressing.
A postauricular subcutaneous tissue pedicled island
advancement flap is well suited for reconstruction of
deep full-thickness conchal defects because of the flap’s
Text continued on p. 601