Introduction
The forehead is the prominent wide area of the human face, between the hairline and the brows. The forehead is divided into five parts - midline (area between brows and hairline), median (adjacent to the midline), lateral (next to median), temporal (side area), and brow (eyebrows). Anatomically, the forehead is the extension of the scalp area. On average, four fingers would fit on the forehead. More than four fingers would fit in a large forehead.
Forehead defects in the forehead may develop from various conditions such as skin cancer, birth defect, deformity, uneven bony structure, etc. The forehead can be contoured, reshaped, or reconstructed to correct these defects.
Currently, forehead reduction is popular, especially among women. The average height of the female forehead is 2.4 inches. Since a wide prominent forehead is believed to be a sign of masculinity, women with similar forehead appearances opt for reduction surgery to reduce the size of their forehead to appear more feminine.
What Is Forehead Reconstruction?
It is a surgical procedure to reconstruct, reshape or reduce the appearance of forehead-related defects due to trauma or cancer and replace the bony structure. It also helps reduce the forehead's dimensions, such as length. This is a major surgical procedure, done under general anesthesia. It is an expensive surgery and the cost may vary depending on various factors; therefore, prior planning is important.
What Are the Types of Forehead Reconstruction?
According to Ousterhout's classification, there are four types:
-
Type I: The frontal sinus is minimal or absent. Contouring of the forehead can be achieved with burring.
-
Type II: The forehead has prominent anterior walls of the frontal sinus. Augmentation with a prosthesis is recommended.
-
Type III: The forehead has over-projected or prominent anterior walls. Osteotomy (the process in which bone is removed, reshaped, and replaced) is recommended.
-
Type IV: The forehead is small and the brow is under-projected. An augmentation procedure is recommended.
What Is Forehead Reconstruction Surgery?
The forehead can be reconstructed using local flaps, skin grafts, regional flaps, or a combination of these. In general, the surgical procedure is done under general anesthesia, and it includes the following steps:
-
The area requiring reconstruction is marked that needs to be reconstructed, removed, or reshaped. Special care must be taken to protect the area's hair follicles and blood vessels.
-
An incision or cut is made along the hairline and forehead area (pretrichial incision). The skin is separated, and the marked area is cut or removed.
-
The hairline incision is joined with the forehead incision. This step shortens the length of the forehead.
-
Any existing bone defect is repaired.
-
The incision is then closed and hidden under the hairline. Sometimes, local flaps from adjacent tissue are used to close the small defects. For larger defects, skin grafts are used.
-
There is minimal scar formation from the surgery; sometimes, the incision is left open for healing.
-
After the surgery, the patient is observed for common signs of healing, such as bruising and swelling, which is normal. These signs go away in a few weeks on their own.
-
The recovery time may vary from patient to patient, but healing signs, such as inflammation, bruising, itching, etc., may disappear in one week. However, in a few cases it may last for two to three weeks.
-
It takes up to six months to fully heal from forehead reduction surgery.
Hydroxyapatite Forehead Reconstruction
Hydroxyapatite is the cement used in forehead reconstruction to replace bone grafts. It is a bone cement made of tetra calcium phosphate and dicalcium phosphate.
Indications of Forehead Flap
A forehead flap is needed when the defects or damages in the skin cannot be repaired or treated through other methods such as primary closure, skin grafts, etc.
How Long From Start to Finish Does Nasal Reconstruction With Forehead Flap Take?
The nasal reconstruction with the forehead flap is done in two or three stages that take several weeks to months.
What Is Type 3 Forehead Reconstruction?
Type 3 forehead reconstruction is done when the frontal sinus bone is too thin to be shaved, or the forehead is over-projected or has prominent anterior walls. The bone is removed, reshaped, and replaced (Osteotomy).
What Is Forehead Graft Plastic Surgery?
It is an old surgical technique used in nasal reconstruction. A graft is taken from the forehead to fill the nasal defects. It is a gold standard technique.
What Are the Different Reconstructive Techniques?
-
Secondary Intention: In this technique, the incision is left open for healing, but it may result in hair loss, mismatched skin color, etc. It is generally used for patients with other health conditions who cannot tolerate anesthesia for longer.
-
Allografts: These are commonly used materials that promote granulation tissue formation and heal defects in the subcutaneous or deepest layer of skin. These are available in various shapes, such as sheets and powder, and can be placed in the defect. The healing takes place through secondary intention.
-
Skin Grafts: When a suitable or favorable wound bed is present in the defect, skin grafts can be used. More commonly, split-thickness skin grafts taken from the thigh area are used.
-
Local Flaps: These are taken from the adjacent tissue and can repair the defect with a similar tissue. There are different types of local flaps - advancement, rotation, and transposition flaps. Generally, local advancement flaps are not used alone in forehead reconstruction.
-
Regional Flaps: The temporoparietal flap is used as a regional flap or a free tissue flap. The Trapezius flap and latissimus dorsi myocutaneous flap are other examples. They are commonly used in patients who have poor healing characteristics.
-
Tissue Expanders: When the local flaps are insufficient, the surrounding tissue is expanded through a tissue expander to close the defect.
-
Free Tissue Transfer: It is used for very large defects and for patients who have chronic conditions. The main disadvantage is the color mismatch.
Complications of Forehead Reconstruction Surgery
Although the chances of complications are low, the possible complications include the following:
-
Hematoma (blood clot under the tissues).
-
Temporary hair loss (alopecia).
-
Nerve damage.
-
Infection after surgery or at the surgery site.
-
Deep venous thrombosis (blood clot formation in the deep veins).
-
Bleeding after surgery.
-
Allergic reactions from anesthesia.
Conclusion
Forehead reconstruction is challenging because of the underlying blood vessels, nerves, and inelastic forehead skin. The forehead is commonly used as a donor site for other reconstruction procedures, such as the nose. There are different reconstruction techniques available for this purpose. The most appropriate technique may depend on the size and location of the forehead defect.
