TECHNICAL STRATEGY
Total Forehead Flap: Hemicraniofacial Giant Congenital
Melanocytic Nevus
Jorge O. Güerrissi, MD
Abstract: Being nonYhair-bearing and relatively thin and having
similar color and texture of the skin of the forehead provide an
excellent characteristic not only for nasal reconstruction but also in
other facial areas. A 28-year-old man presented in the Department
of Plastic Surgery, Argerich Hospital, Buenos Aires, Argentina, with
a giant congenital melanocytic nevus extended on complete left
cheek, total nose, both upper and lower lids, ocular globe, and tem-
poroparietal region. Tumor resection and reconstructive aspect were
planned in 3 stages. (1) Excision of the tumor located in the cheek,
nose, and both upper and lower left lids. The reconstruction of the
cheek was made with a total forehead flap. The nose was resurfaced
by means of a total skin graft. (2) resection of the temporoparietal
nevus. (3) Treatment of the tumor involving the ocular structures.
Total forehead flap was outlined, permitting carryout of skin of the
total forehead area, and the blood supply was originated from the
frontal and parietal branches of the temporal superficial artery and
secondarily by anastomosis with the branches arising from both
homolateral auricular and occipital vessels. Postoperative control 1
year after surgery showed an excellent aesthetic and functional re-
sult not only in the recipient area but also in the donor area.
Key Words: Hemifacial reconstruction, forehead flap, giant
melanocytic nevus
(J Craniofac Surg 2009;20: 522Y524)
F orehead flaps have been successfully used from many years in
total or partial reconstructions of the nose.1Y3 A variety of fore-
head flap have been reported during the last 6 decades, including
the median, paramedian, sickle, and the oblique patterns.3,4
Being nonYhair-bearing and relatively thin and having simi-
lar color and texture of the skin of the forehead provide an excellent
medium for nasal reconstruction. Such characteristics have demon-
strated that the forehead is the time-honored donor site not only for
nasal reconstruction but also for other areas of the face.
In 2002, the author reported successful use of forehead flap
for total lower lid reconstruction.5 Based on the excellent aesthetic
and functional result obtained in lid reconstruction, forehead flaps
have been planned for surgical reparation in different areas of
the face.
From the Department of Plastic Surgery, Argerich Hospital, Buenos Aires,
Argentina.
Received October 2, 2007.
Accepted for publication October 7, 2007.
Address correspondence and reprint requests to Jorge O. Güerrissi, MD,
Libertad 985, Quilmes 1878, Buenos Aires, Argentina; E-mail: guerrisi@
speedy.com.ar
Copyright * 2009 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0b013e31818434df
522 The Journal of Craniofacial Surgery
Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
According to anatomy and actual concepts on cutaneous
flaps, a new axial pattern flap carrying total frontal skin has been
studied.
In this article, a forehead flap including the skin of the total
fontal area (TFF) is proposed for reconstruction of complete cheek
area and upper and lower lids, after resection of giant congenital
melanocytic nevus.
MATERIALS AND METHODS
A 28-year-old man presented in the Department of Plastic
Surgery, Argerich Hospital, Buenos Aires, Argentina, with a giant
congenital melanocytic nevus extended on complete left cheek, total
nose, both upper and lower lids, ocular globe, and temporoparietal
scalp region (Fig. 1).
The tumor involved also the ocular and palpebral conjunctiva
and sclera of the ocular globe. Tumor resection and reconstructive
aspect were planned in 3 stages: (1) excision of the tumor located
in the cheek, nose, and both upper and lower left lids; reconstruc-
tion of the cheek with total forehead flap; for the nose, a total skin
graft will replace the resected nose tissues; (2) resection of the tem-
poroparietal nevus; and (3) treatment of the tumor involving the
ocular structures.
A TFF was planned using the nonYhair-bearing skin of
complete forehead area maintaining intact the hairline, eyebrows,
frontal branches of both seventh cranial nerves, and both frontal
muscles (Fig. 2).
The outlined flap was designed according to the blood sup-
ply originated from: (1) both parietal and frontal branches of the
right superficial temporal artery, and (2) right auricular and occipi-
tal arteries (Figs. 3A, B).
All tissues of the scalp are included in this extended flap,
except in the forehead area where only the skin is mobilized
(Figs. 4A, B).
The surgical reconstruction was made in 2 stages: (1) after
complete cheek tumor resection, a total forehead flap was
transposed, covering total cheek area and both upper and lower
right lids; and (2) after 21 days, the flap is divided (section of
pedicle); the scalp hair-bearing was returned to the cranium, and
definitive skin graft was placed on the forehead area. Simulta-
neously, the nevus of the nose was resected and replaced by a total
skin graft.
Postoperative evaluation at 12 months revealed good aesthetic
and functional result (Fig. 5). No complications were observed.
Further secondary operations will be programmed accordingly, with
final eyebrow reconstruction and treatment of the nevus in both the
temporoparietal region and ocular globe and annexes.
DISCUSSION
The forehead is the time-honored donor site for nose re-
construction; it can be used in various ways, depending on the size
and position of the area to be resurfaced and whether the nose
reconstruction is total or partial.
& Volume 20, Number 2, March 2009
The Journal of Craniofacial Surgery & Volume 20, Number 2, March 2009 Total Forehead Flap

FIGURE 1. Preoperative views of the giant congenital melanocytic nevus extended to the total right hemiface, upper and
lower lids, nose, temporoparietal region, and ocular globe and annexes.

FIGURE 2. A, The skin of the total forehead area is included in the flap design. B, Superior view shows complete scalp tissue that
must be mobilized. C, The upper incision, extended on the medial line of the scalp, ensures a wider arch of rotation of the pedicle.

Converse6 described the anterior scalp flap, which transferred
the skin of one half of the forehead. It is based on the contralateral
vascular supply of the scalp; it was developed as a variation of
Gillies’7 up-and-down flap, and it includes not only the forehead
skin but also the scalp, galea with its vascular pedicles derived from
vessels of the forehead, and anterior portion of the scalp.
Despite the necessity of a 2-stage procedure, this technique
continues to have specific applications for the reconstruction of to-
tal and partial nose defects for which there are color match and
tissue pliability. Because of its safe irrigation, useful pliability, and
color and texture match, the forehead flap has been successfully
used in reconstruction of other facial areas such as the lids.5
In the case presented in this article, a different flap from
Converse’s one was planned for reconstruction of the total left
cheek area and both upper and lower lids using the tissues of the
forehead region.
Both total skin nonYhair-bearing and scalp of the forehead
region were included in the TFF; the last lines of hair on the left
site of the forehead were used for left eyebrow reconstruction. The
forehead flap includes the skin and galea, but frontal muscles and
the frontal branches of the facial nerves must not be injured, main-
taining intact the functional unity. It will allow normal wrinkles
appearance in the grafted skin, and also unaesthetic depression
may be avoided.
A total skin graft taken from the inferior abdominal area was
applied on the forehead area, which permits total reconstruction.
Dominant vasculature was outlined from superficial temporal artery
with its 2 principal branches as parietal and frontal; auricular pos-
terior and occipital arteries were also recruited, maintaining safer
flap irrigation (Fig. 3B). This frontal flap is described as an axial
pattern flap of the direct cutaneous system.8
The skin of the frontal area is nourished principally by
frontal and parietal branches of temporal superficial artery and
secondarily by anastomosis with the branches arising from both
homolateral auricular and occipital vessels. Venous drainage of the
frontal region is carried out by an extended net; skin veins of this
area have no valves and present a quick and wide drainage.9
The use of total skin of the forehead area presents more
advantages compared with Converse’s flap or other partial forehead
flaps, as follows: (1) carries up more skin when a great facial area
must be reconstructed, (2) grafting of the total donor forehead area
produces better aesthetic result than partial one, (3) hairlines can
be used for eyebrow reconstruction, and (4) the final scars remain
occult in the hairline and eyebrow limits.
Disadvantages are similar to those of the classic forehead
flap, in that a second surgical stage must be made. After 3 weeks,
the pedicle must be divided, and the hair-bearing scalp is returned
to donor scalping area.
FIGURE 3. A, Lateral aspect of the flap design: arterial pedicles
(in the skin). B, Schematic drawing of the principal pedicles.

* 2009 Mutaz B. Habal, MD 523

Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Güerrissi The Journal of Craniofacial Surgery & Volume 20, Number 2, March 2009

FIGURE 4. A, Extended defect after removal of melanocytic lesion. B, Intraoperatory views showing the mobilization of the
flap. C, Translation of the flap to the right hemiface, according to surgical planning.

FIGURE 5. Follow-up 12 months after surgery.

The functional and aesthetic results were satisfactory for the
patient and for us.
The skin of the forehead area permits total cheek recon-
struction including both upper and lower lids contributing to main-
tain the hemiface aesthetic unity.
When more tissues are necessary for extended and complex
reconstruction, the use of tissue expansion in the frontal region
will permit more skin for such a repair.
In conclusion, when a great area of the face must be recon-
structed, the skin of the total forehead area can be successfully used
because its skin has color and texture match, excellent pliability, and
safe irrigation. On the other hand, the aesthetic aspect of the total
forehead grafted is uniform, as total donor area looks similar in tex-
ture and color, with maintenance of the aesthetic aspect.
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2. Gillies HD. Plastic Surgery of the Face. London, UK: Oxford University
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3. Jackson IT. Nose reconstruction. In: Jackson IT, ed. Local Flaps in
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4. Cheney ML, Urken ML. Anterior y posterior scalp. In: Urken ML,
Cheney ML, Sullivan M, et al, eds. Atlas of Regional and Free Flaps
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JG, ed. Plastic Surgery. Volume 1. Philadelphia, PA: Saunders,
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524 * 2009 Mutaz B. Habal, MD

Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.