Mainak Mallik, Santanu Suba


Introduction: Forehead and temple reconstruction poses a difficult challenge to the plastic surgeon owning to the aesthetical tantrums, non-hair bearing skin with hairline posteriorly into the scalp and the eyebrows and glabella in front. As per the nature and size of the defect a wide array of options ranging from skin grafting, tissue expansion, loco-regional flaps and microvascular free flaps are available and are customized in terms of the characteristics of the defect. Often higher microsurgical free tissue transfer is required in relatively smaller defects.

Aims and objectives: This retrospective descriptive non-randomized purposive study over six months at a Government Medical College aimed at executing different free microvascular flaps and to assess the technical details, operative outcome and short term follow up with the rationale behind choosing each specific reconstruction.

Methodology: Patients were selected based on the defects to be reconstructed, the pre operative work up and anesthesia check up were done, they were admitted and operated. Planning in reverse was done in every case, the source vessels and the perforators were identified and marked with hand held Doppler pre-operatively, the primary defect defined after excision and the flaps were harvested, inset given and donor sites managed accordingly. Post-operatively the flaps were monitored clinically, the complications and issues addressed, dressings changed on frequent intervals and results interpreted. After discharge, they were followed up at regular intervals.

Results: Out of 5 free flaps (2 radial artery forearm, 2 ulnar artery forearm and 1 latissimus dorsi myocutaneous flaps) in 5 patients, all flaps survived. Superficial temporal vessels end to end were used in all cases as recipient vessels for microvascular anastomosis. The mean size of the defects was 13 x 5.8 cm (mean surface area was 75.4 cm2). The mean operative time was 5.5 hours. There were minor complications of partial necrosis of 1 latissimus dorsi muscle flap in 1 patient and donor site issue of hypertrophic unsightly scar in forearm in another patient. All other wounds and donor sites healed well. The mean post-operative hospital stay was 6 days.

Conclusion: In cases of defects in aesthetically important forehead and temporal regions with exposed calvarial bones not amenable for full thickness skin grafts or local flaps, free tissue transfer from non-hair bearing skin with good colour and texture should be considered as a primary option safely.


Forehead reconstruction, free microvascular flaps, free ulnar artery forearm flaps.

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