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Introduction

In the majority of cases of frontal defect, it has been shown that the defect is borne of the wide excision of malignant cancers or through traumatic impact, with a number of procedures having been proposed to resolve the issue. Within the diverse range of proposals, Ragip Ozdemir, M.D. et. al. have produced numerous works on versions of superficial temporal artery island flaps designed specifically for facial reconstruction ¹.  Alongside these, the current paper brings to the fore an innovative flap, the purpose of which is to cover a frontal defect without skin graft, and which comprises of a circle five centimeters (5 cm) in diameter, covering both non-hair and hair bearing wounded areas.

Case Report

An 82-year old male sustained squamous cell carcinoma, a tumor which had previously been operated upon on three separate occasions. On the first occasion, the patient accepted excision at a local medical department having been under the impression that he was suffering from nevus. The wound, nevertheless, remained wet and failed to heal over a subsequent two-week period. On the second occasion, at which point he was being treated at this facility, the wound presented itself instead as a chronic ulceration. Having gained the impression of atheroma, we performed excision and Z-plasty to close the wound, and then sent the specimen up to pathology for testing.

The results obtained from the specimen led to a change in our diagnosis, one week later, to squamous cell carcinoma. As a result, an operation involving wide excision and bilobate flap reconstruction was subsequently arranged, with an additional 1.5 cm margin of freedom with which to work.

Three months later, the patient returned to our clinic complaining of a recurrent skin protrusion. Upon explanation to both the patient and his family, of the identifying trait of the tumor and the rate of recurrence, the patient agreed to undertake a further operation involving wide excision and reconstruction. On this occasion, however, the patient expressed concern over his appearance and requested that we try to preserve his normal appearance such that he could continue uninterrupted participation in social activities. Thus, this 5-cm diameter flap was designed to restore the frontal defect, following a wide excision (involving an additional 2cm), inclusive of skin , hair bearing scalp and periosteum.

Methodology and Anatomy

The superficial temporal artery is one of the terminal branches of the external carotid artery, which begins at the parotid glands behind the mandibles and the neck, and then crosses the posterior root of the zygomatic process of the temporal bone. At a point of approximately 5 cm above the zygomatic process, it then separates into the anterior frontal and posterior parietal branches.***²³

The two branches are used as a distal base to provide this perforator flap, which is pierced by the superficial temporal artery (fig 1.). The oval-shaped fasciocutaneous flap is designed in such a way that it is just large enough to easily close the donor site, thus concealing the frontal defect. After marking the superficial temporal artery pathway, the wide excision area, and the oval-shaped flap design, the tumor is excised along with periosteum. Thereafter, an area of approximately 1mm thickness of the outer cortex of the frontal bone is rubbed out. The flap is harvested from the anterior and inferior margins along the depth of the superficial musculoaponneurotic system (SMAS), upwards and towards the flow-through area of the superficial temporal artery. The aim should be to preserve as much as possible of the artery covered by the flap before ligating its proximal end in order to increase its blood supply.

Finally, the flap is elevated by tracing back the superficial temporal artery distal to the pivot point. The frontal defect and donor site can then be directly closed after undermining the subcutaneous tissue.   

Discussion

The previous literature in this area has reported the availability of numerous procedures aimed at concealing frontal defects, including skin grafts, local or free distal flaps [***⁴⁵⁶⁷⁸⁹], and tissue expansion [***10,11,12,13]. The color and texture of local tissue is invariably superior to any type of graft or flap brought in from a distant donor area; indeed, the facially aesthetic results yielded by such alternative distal grafts or flaps are particularly poor. Although the alternative, tissue expansion, can produce aesthetically-pleasing results, it does present a number of risks, including the deterioration of overlying skin quality, the unknown potential for later contraction and a delay to the reconstruction start time [***14].

In this case, it was particularly difficult to restore the frontal defect (including non-hair and hair bearing areas) without a skin graft. The superficial temporal artery is the terminal branch of the facial artery, with the pedicle flap arising from this artery currently being used as a first choice local flap for both scalp and facial reconstruction. Many versatile flaps originate from the superficial temporal artery [***1]; indeed, Ragip Ozdemir, M.D. et al. have reported five such versatile flaps based on this artery: (i) the superiorauricular artery island; (ii) the anterofrontal island; (iii) the centrofrontal island; (iv) the posterofrontal island; and (v) the parietal island flaps.  This article proposes an additional, novel perforator flap (distally based from this artery) for the reconstruction of frontal area defects.

Summary

The benefits of applying this new flap include ease of dissection, a reliable pedicle, well skin color and texture matching, a single stage procedure, minimal donor-site morbidity, no requirement for skin grafting. Besides it can use one sideburn to cover the hair bearing areas of the frontal defect. The only shortcoming is that it may be specific to the senior population.

Fig.1.         The flap is designed oval shaped, so as to provide direct closure. The plus sign (+) indicates the pivot point of the flap, with the wide excision area covering the tumor, the 2cm free margin and partial bone cortex.

Figs 2 and 3.         Six months after reconstruction, the follow-up photographs present an acceptable appearance; the sideburns are used to cover the original hair-bearing scalp.