Question Bilateral 15733

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Procedures:
1. Forehead reconstruction with right superficial temporal artery flap 15733

2. Forehead reconstruction with left superficial temporal artery flap 15733-51

3. Debridement of forehead wound (19.89 square cm) 11043-51


MOHS excision of a central forehead basal cell carcinoma on 1/7/21. The procedure resulted in a 4.7cm x 3.4cm full thickness defect of the central forehead. I recommended reconstruction of the central forehead defect with bilateral superficial temporal artery myocutaneous flaps .

Inspection of his forehead showed a central full thickness defect 4.7cm in height x 3.4cm in width, with exposed frontal bone in base of the wound, as well as devitalized skin and soft tissue at the margin. The wound margins, forehead, frontal scalp, temporal scalp, temporal face and brows were infiltrated with tumescent local anesthesia. The central forehead wound was sharply debrided with a #15 blade scalpel of all fibrinous exudate, granulation tissue, and devitalized skin, from the skin down to the frontal bone, until healthy viable flap margins with bright red punctate bleeding were established. The area of debridement and size of the resulting defect measured 5.1 cm in width by 3.9cm in height (19.89 square cm).

I then proceeded with development of the bilateral superficial temporal artery myocutaneous flaps based on the bilateral frontal branches of the superficial temporal arteries. Working laterally from the margins of the defect, the forehead was elevated in the plane between the frontalis muscles and the frontal bone periosteum. Laterally, the flaps were dissected between the temporoparietal fascia and the temporalis muscle fascia, taking care to preserve the bilateral frontal branches of the superficial temporal arteries.

Incisions were made just superior to the eyebrows and carried inferior-laterally around the orbital rim as well as across the frontal hairline extending along the junction of temporal and frontal scalp to allow for advancement of the flaps. At the eyebrows, the supraorbital, supratrochlear, and lacrimal neurovascular bundles were carefully dissected free from the surrounding soft tissue with a McCabe dissector. The frontal scalp was also undermined to facilitate closure. Hemostasis was obtained with the bipolar electrocautery. The wound was irrigated copiously with triple antibiotic solution.

The bilateral superficial temporal artery myocutaneous flaps were then advanced to approximate one another and then inset in layers. The frontalis and galea aponeurosis were approximated with interrupted 3-0 vicryl sutures. The deep dermis was approximated with interrupted 4-0 monocryl sutures. The skin was closed with 5-0 prolene along the brows, 6-0 prolene at the forehead, and 5-0 plain gut along the hairline. The hairline closure was reinforced with staples.
 
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