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The endoscopic excision of a forehead osteoma is reported. This method leaves no scars in the forehead, results in positive excision of the tumor, and involves no complications such as nerve damage or vascular injury with direct endoscopic vision. It is considered to be an excellent procedure with respect to cosmetic results.
J. M. Converse described the scalping forehead flap in 1942 with the aim of using it in total nasal reconstruction. A rich net of arterial and venous vessels constitute the basic pattern of its blood supply through three principal pedicles: (1) temporal superficial, (2) supraorbital, and (3) supratrochlear. It was described for nasal reconstruction, but due to its characteristics, such as color of the frontal skin, texture, hairless skin, and reliable irrigation, it can be used in the reconstruction of other facial areas. According to these particularities, the Converse flap was used in the reconstruction of a total left lower lid and adjacent lateral nose and cheek areas in a patient with an extended squamous carcinoma. The tumoral resection included the removal of (1) complete lower lid, (2) lacrimal lower canaliculus, sac, and nasolacrimal duct, (3) lower ocular conjunctiva, (4) intraorbitary fat and both inferior oblique and inferior rectus muscles, and (5) adjacent skin of the nose and cheek. Postoperative controls showed an excellent aesthetic and functional result. A hypochromic frontal skin graft was the only sequela; definitive skin coloration was obtained by a dermopigmentation technique. The versatility of this forehead flap allows it to be successfully used for reconstruction not only in the nasal area but also in other facial ones.
Two representative cases of repair of forehead defects using a modification of the subcutaneous pedicle flap are reported. Complications are minimal if proper technique is followed. Application of this flap to include difficult donor areas, such as the scalp and forehead, should be considered.
In 6 fresh cadavers, an injection study of the facial vessels with disulfine blue dye and Microfil demonstrated visualization of large-caliber vessels of the median forehead skin even when the supraorbital and supratrochlear vessels were interrupted. The results of the study would suggest that the median forehead flap can be elevated without incorporating the supratrochlear vessels, but the flap design should be reserved for those clinical situations where the pedicle must be extensively mobilized, e.g., reconstruction of the nasal tip and columella and the presence of a low-lying frontal hairline.
A physical anthropologic basis for aesthetic evaluation of the supraorbital ridges and forehead is described. The structures included for evaluation and possible treatment are the supraorbital ridges, relation of the orbital walls to the eyes, the temporal ridges, and slope of the forehead. All can be altered by reduction contouring or augmentation using methods described. Twenty-one patients are presented having procedures for purely aesthetic reasons. If more than 5 to 6 mm of augmentation or reduction is desired, the deformity is more than aesthetic and should be treated by a craniofacial team. The aesthetic restructuring procedures described are done using tissue localized to the cranium and have proven to be safe and free of complications in the patients treated. Physical anthropology helps to put the aesthetics of these procedures on a firmer basis and to determine which patients may require more than an extracranial aesthetic procedure.
Satisfactory forehead reconstruction can be accomplished by microsurgical free tissue transfer. Basic principles of forehead resurfacing include: (1) replacement with similar quality soft tissue as a well-defined complete aesthetic unit, (2) establishment of the hairline 5-6 cm above the eyebrows, and (3) use of adjunctive procedures to enhance the aesthetic result. We have found the radial forearm flap and the groin flap to be excellent flaps for achieving this goal.
Placement of screws at the posterior aspect of the incision sites and the gradual placement and removal of staples behind the screws allow for a controlled and titrated elevation of the forehead and brows. This technique does require the patient's acceptance of the temporary placement of screws and staples into the scalp, which in my experience has not been a problem. By seating the patient upright on the operating table, the surgeon can intraoperatively make a direct evaluation and adjustments (removal or addition of staples). This approach leads to a more controlled elevation of the forehead and brows and the potential of a more symmetrical and satisfactory result.
Elicitation of the oculocardiac reflex is a well-documented phenomenon encountered during ophthalmologic surgical procedures. Familiarity with and prompt recognition of this entity has significantly reduced the morbidity associated with it; however, potentially lethal arrhythmias and cardiac arrest still occur. We report elicitation of the reflex during manipulation of the supraorbital nerve during endoscopic forehead lift surgery. To our knowledge this is the first case of elicitation of the oculocardiac reflex reported during endoscopic forehead lift surgery.
The use of the frontalis musculocutaneous flap as a pedicle island flap offers some advantages in frontal reconstruction. It can be used for immediate reconstruction following the ablation of a small or moderate area, even after harvesting of the frontal flap for nasal reconstruction. Because of its intact lateral bundle, it has the potential to carry some sensory innervation, albeit minimal, to the reconstructed area. We have found the frontalis musculocutaneous flap, when used as a pedicle island flap, to be an adaptable and dependable alternative flap for repairs after small or moderate resections in the frontal region. This flap could be performed immediately and in one stage, have a low morbidity rate, and allow a rapid aesthetic restoration; and, it is easy to perform. In two cases, we have observed some degree of venous congestion in the island during the early postoperative period but with success in final healing. The experience demonstrates that this flap should be considered as another valuable tool in reconstructive efforts directed at the forehead. We propose a novel method for the forehead reconstruction using the frontalis musculocutaneous island flap. A case is presented that demonstrates the use of this flap for repair in a depressed frontal defect.
BACKGROUND: With endoscopic forehead rejuvenation, most surgeons use at least two points of fixation for each eyebrow, often including some type of bone fixation, to achieve the aesthetic goal of lasting repositioning of the eyebrows and elimination of frown lines. In this prospective study, short-term and 1-year postoperative changes in the position of the eyebrows following extensive release of eyebrow-retaining ligaments and use of single-point fascial suture (without bone fixation) were objectively evaluated. METHODS: Front-view, life-size photographs of 48 patients undergoing endoscopic forehead surgery for treatment of migraine headaches were analyzed preoperatively and 1 and 12 months postoperatively. The distance of the caudal portion of each eyebrow from a horizontal line passing through the medial canthi was measured at three levels: (1) the lateral canthus, (2) midpupil on a straight gaze, and (3) medial canthus. RESULTS: Statistical analysis revealed a significant elevation of the eyebrows at each of these three reference points when preoperative and 1-month postoperative data were compared (p = 0.001). Twelve months postoperatively, the eyebrows remained significantly elevated at each of the three reference points on both the left (p = 0.001) and right (p = 0.001) sides. Comparison of data at 1 and 12 months postoperatively did not show any statistically significant difference (p = 0.1 to 0.9 at the three levels), indicating that the eyebrow elevation was maintained. CONCLUSIONS: The authors conclude that wide release of the eyebrow-retaining ligaments with single-point fascial fixation is an effective method for elevation of the eyebrows, and that bone fixation should be used when an alteration of eyebrow arch form or correction of eyebrow asymmetry is indicated.
Assuming that an agonistic function is present to maintain an adequate visual field, we hypothesized that stretching of the mechanoreceptor of Mueller muscle induces involuntary contraction of the occipitofrontalis muscle, as well as the levator muscles. In patients with aponeurotic blepharoptosis, both unilateral instillation of phenylephrine to contact Mueller smooth muscle fibers and unilateral aponeurotic fixation ipsilaterally reduced the eyebrow height during primary and upward gazing. Bilateral aponeurotic fixation bilaterally reduced the eyebrow height, with fewer forehead wrinkles. Stretching of the mechanoreceptor of Mueller muscle induces involuntary contraction of the bilateral levator muscles. Its increased stretching may induce involuntary contraction of the ipsilateral occipitofrontalis muscle via the mesencephalic trigeminal nucleus and the facial subnucleus as another stretch reflex. The involuntary contraction of the occipitofrontalis muscle that causes forehead wrinkles during primary gazing can be corrected by the aponeurotic fixation to reduce the stretching of Mueller muscle.
Peptococcus saccharolyticus was a numerically important constituent of the bacterial flora of the forehead of 20% of 40 subjects. 16 of these subjects were studied over periods of 12 to 54 mo. It was consistently absent from 12 subjects, was present on every test of 3 subjects, and constituted 96 to 100% of the total flora on 1 subject tested 8 times in a 16-month period. On the forehead of one subject, Peptococcus saccharolyticus was recovered in only 1 of 5 tests.
Measurement of Sebum Excretion Rate (SER) in patients is a time-consuming test. It is now possible to measure SER 1 h after having degreased the forehead with a 70% ethanol solution. The skin surface lipids (SSL) collected during this time have similar composition to those collected for up to 7 h. A qualitative and quantitative study of sebaceous excretion, on 18 volunteers, from 1 to 7 h after having cleansed the forehead, showed that the refatting kinetics, in all subjects, obeyed the same mathematical law, independent of the subjects' individual SER.
A 42-year-old man presented with a 3 month history of erythema and thickening of the forehead skin. He had been diagnosed as hypothyroid 10 years previously and treated with thyroxine at adequate dosage, according to thyroid function tests. Histology confirmed a myxoedematous infiltrate. The forehead is an unusual site for deposition of mucin and the late appearance, 10 years after treatment, is also uncharacteristic. Myxoedema in the usual pretibial site is a feature of Graves' disease. This man, however, had been hypothyroid with no features of Graves' disease suggesting that there are additional factors other than thyroid status and thyroid autoimmune disease which may be important in the development of myxoedematous infiltrates.
Pedicled flaps from the forehead are very useful for covering defects on the nose. A flap from a lateral or the medial part of the forehead can be designed according to the size and site of the defect on the nose. Flaps may even be used to repair full-thickness defects in the nose by grafting skin on their inner surfaces. Such techniques are briefly described step by step.
A case of forehead lipoblastoma simulating a hemangioma in a male infant is reported, to alert pediatricians to this rare tumor and to increase the index of suspicion in atypical hemangiomas. A 2-month-old male infant developed a protruding forehead mass with increased vascularity. It demonstrated progressive and accelerated growth over the subsequent 6 months, unresponsive to steroid therapy. A magnetic resonance imaging scan supported the diagnosis of hemangioma because of the hypervascular nature of the lesion. Surgical excision was performed because of visual obstruction. Pathologic examination of the specimen was consistent with a very primitive lipoblastoma. This tumor is a rare, benign lesion of immature fat cells that is found almost exclusively in the pediatric population. Lipoblastomas are more common in males than females and frequently present as asymptomatic, rapidly enlarging, soft lobular masses on the extremities. Complete surgical excision is the definitive treatment. In the vast majority of reported cases, however, the preoperative diagnosis was incorrect, underscoring the diagnostic dilemma presented by these rare tumors.
A forehead neurovascular island flap has twice been used for reconstruction of minor full thickness nasal defects caused by surgical removal of malignant tumours. The flap was raised one month before transposition, and a split thickness skin graft was applied to the inner surface of the galea of the flap. The periosteum of the forehead was also grafted, thus repairing the donor site before the flap was removed. The flap is based on the supraorbital artery, which was dissected to its origin at the incisura or supraorbital foramen. The advantages are those of a small flap with external as well as internal lining and with preserved sensibility.
UNLABELLED: Electromyographic coactivation of the sternocleidomastoid muscle (SCM) during masticatory function was observed. To analyze the mechanism of the coactivation, we studied the reflex responses of the SCM induced by mechanical stimulations and tooth-tapping movements. Six healthy subjects with an average age of 26 years were asked to make various kind of efforts using SCM and masseter muscles, then the mechanical taps were applied to a forehead and an upper anterior tooth, and the surface EMG from the SCM and masseter were recorded. The head position during the recordings was controlled in the upright or the rotation position. The gingiva of the tapped teeth was anesthetized in two subjects. EMG signals were rectified and digitized and then analyzed using the signal average program on a computer (NEC SANEI 7T17). RESULTS: 1. Reflex responses of the SCM with a latency of ca. 30 ms were induced by mechanical taps to the forehead and to the anterior tooth. It can result from a stretch reflex. 2. During the tooth-tapping movement at 1 Hz, the SCM activated at ca. 90 ms after teeth contacts. It is Possible that the activity was derived from a central control mechanism or from another reflex other than the stretch reflex.