Bilateral Rectangular Musculocutaneous Advancement Flap: A Viable Alternative for Reconstruction of Large-Sized Forehead Defects with Exposed Bone

Abstract

Reconstruction of large-sized forehead defects with exposed bone is challenging, as the forehead is an esthetically important area and the complex courses of the sensory nerves make them prone to damage during reconstruction. The purpose of this study was to achieve forehead reconstruction by predicting the pathways of the forehead sensory nerves and applying an operative technique that minimizes sensory nerve injury. We classified forehead sensory nerves that traverse the flap into five types according to their course, defined the frontalis muscle piercing line that allows for intuitive prediction of a nerve course, and devised a surgical technique for each nerve type. Next, we applied the techniques to a bilateral rectangular musculocutaneous advancement flap to reconstruct a large defect on the forehead caused by squamous cell carcinoma. No complications were observed except partial skin necrosis of the flap that healed spontaneously. Although tension and restricted early movement of the forehead was observed, it resolved within 2 weeks. After 5 months of treatment, the transverse scars were camouflaged by the skin creases and the sensory nerves of the forehead were intact.