Handheld Doppler Detection and Light Illumination for Vascular Mapping in Nasal Reconstruction.

BACKGROUND: The application of the expanded forehead flap in nasal reconstruction has the advantage of being able to provide a sufficient amount of flap and can provide good aesthetic results. For an expanded forehead flap to survive, there must be adequate arterial supply and venous return. Despite this, limited studies have been conducted on preoperative vascular mapping and the design of the expanded forehead flap for nasal reconstruction. In this article, the authors present a technique of hand-held Doppler detection with light illumination for vascular mapping. PATIENTS AND METHODS: The study included patients who underwent total nasal reconstruction with expanded forehead flaps between May 2016 and April 2021. The design of the flap was based on the result of preoperative vascular detection by hand-held Doppler detection assisted by light illumination. RESULTS: A total of 32 patients underwent total nasal reconstruction with an expanded forehead flap. The distal part of the flap became necrotic 1 week after the surgery in 2 patients. Following dressing changes and the administration of antibiotics, the distal flap in these patients survived well. No complications were reported in the long term. CONCLUSIONS: Hand-held Doppler detection combined with light illumination is a convenient and effective preoperative design method for nasal reconstruction with an expanded forehead flap. All flaps survived well in the long term. LEVEL OF EVIDENCE: Level IV.

Anatomic Variations of the Lateral Branch of the Supraorbital Nerve Observed in Endoscopic Forehead Surgery.

Surgeons dissect carefully in the medial third of the supraorbital rim to preserve the supraorbital nerve (SON) during surgical forehead rejuvenation. However, the anatomic variations of SON exit from the frontal bone have been researched in cadaver or imaging studies. In this study, we report a variation in the lateral branch of SON observed in an endoscopic view during forehead lifts. A retrospective review of 462 patients who underwent endoscopy-assisted forehead lifts between January 2013 and April 2020 was performed. Data, including the location, number, and form of the exit point and thickness of SON and its lateral branch variant, were recorded and reviewed intraoperatively, utilizing high-definition endoscopic assistance. Thirty-nine patients and 51 sides were included, and all patients were female, with a mean age of 44.53 (18-75) years. This nerve exited a foramen in the frontal bone ~8.82 ± 2.79 mm lateral to SON and ~1.89 ± 1.34 mm from the supraorbital margin vertically. Observed thickness variations of the lateral branch of SON included 20 small, 25 medium, and 6 large nerves. This study revealed various positional and morphologic variations of the lateral branch of SON in an endoscopic view. Thus, surgeons can be alerted of the anatomic variations of SON and establish careful dissection during procedures. In addition, the findings of this study will be useful in planning nerve blocks, filler injections, and migraine treatments in the supraorbital region.

An Exploration of the Anatomy of the Forehead of Asians and Its Relationship With Forehead Lines Based on Ultrasound Imaging.

BACKGROUND: A profound understanding of the various frontal tissues' morphology and their relationship with forehead lines can efficiently guide clinical treatment. OBJECTIVES: The authors explored the relationship between frontal anatomy and frontal lines. METHODS: We measured the thickness and shape of tissues in different regions of the forehead of 241 Asians. Then, we analyzed the relationship between the types of frontalis muscle and frontal lines, as well as the relationship between the frontal anatomical structures and the production of frontal lines. RESULTS: We classified the types of frontalis muscle into 3 categories comprising 10 subtypes. The skin (0.78 mm vs 0.90 mm, P < .05), superficial subcutaneous tissue (0.66 mm vs 0.75 mm, P < .05), and frontalis muscle thickness (0.29 mm vs 0.37 mm, P < .05) of people with obvious dynamic forehead lines were significantly thicker than those of people without significant dynamic forehead lines. However, no significant difference in the deep subcutaneous tissue thickness was found between people with and without static forehead lines (1.36 mm vs 1.34 mm, P < .05). CONCLUSIONS: This study shows the relationship between the frontal structure and frontal lines. Therefore, these results can provide references for treating frontal lines, to a certain extent.

Endoscopic Approach for Resection of Frontal Forehead Osteoma: Technical Case Report Instruction.

Forehead osteomas are benign bone tumors. They are frequently associated with exophytic growth in the outer table of the skull, causing cosmetic disfigurement of the face.1-9 The objective of this study was to present the efficacy and feasibility of the endoscopic treatment of forehead osteomas by presenting a case report with details of the surgical technique. A 40-year-old female patient presented with aesthetic complains of a progressing bulge in the forehead. A computed tomography scan with 3-dimensional reconstruction showed bone lesions on the right side of the forehead. The patient underwent surgery under general anesthesia with no noticeable incision, which was planned 2 cm behind the hairline in the midline because the osteoma was close to the midline plane on the forehead (Video 1). A retractor coupled with a 4-mm channel for endoscopy and a 30-degree optic was used to dissect, elevate the pericranium, and locate the 2 bone lesions in the forehead. The lesions were removed using a chisel, endoscopic facelifting raspatory, and a 3-mm burr drill. The tumors were resected completely, resulting in good cosmetic outcomes. The endoscopic approach for treating forehead osteomas is less invasive and facilitates complete removal of tumors, which results in good cosmetic outcomes. Neurosurgeons should consider and add this feasible approach to enhance their surgical armamentarium.

Comparative analysis of original face and skin-warped average face images for the scoring of skin attributes.

OBJECTIVES: Representative of a panel, an average face image could be used to analyse/display skin changes while alleviating image rights constraints. Therefore, we used landmark-based deformation (warping) of individual skin images onto their panel's average face, evaluating this approach's relevance and possible limits. METHODS: An average front face image was constructed from images of 71 Japanese women (50-60 years old). After warping individual skin images onto this average face, the resulting skin-warped average faces were presented to three experts who graded: forehead wrinkles, nasolabial fold, wrinkle of the corner of the lips, pore visibility and skin pigmentation homogeneity. Two experts estimated subjects' age. Results were compared to gradings performed on original images. RESULTS: Inter-expert grading shows excellent to good correlation whatever image type: from 0.918 (forehead wrinkles) to 0.693 (visibility of pores). Correlations between scoring of both image types are almost always higher than inter-expert correlations (maximum: 0.939 for forehead wrinkles-minimum: 0.677 for pore visibility). Frequencies of grades/ages are similar when scoring original and skin-warped average face images. Experts scores are similar in 90.6%-99.3% of the cases. Average deviations upon scoring both image types are smaller than average inter-expert deviations on original images. CONCLUSIONS: Scoring facial characteristics in original images and skin-warped average face images show an excellent agreement, even for perceived age, a complex feature. This opens the possibility of using this approach to grade facial skin features, monitor changes over time, and to valorise results on a face deprived of image rights.

Subcutaneous fat infiltration into the dermal layer induces wrinkle formation.

BACKGROUND: Wrinkles appear with aging, producing an aged impression, but the mechanism of wrinkle formation has not yet been fully elucidated. We recently reported that subcutaneous fat infiltrates into the dermal layer with aging and impairs skin elasticity, but the contribution of this process to wrinkle formation is still unclear. PURPOSE: We aimed to clarify the contribution of dermal fat infiltration to wrinkle formation by analyzing the relationship between them in the forehead of female volunteers. METHODS: We measured the severity of fat infiltration in the forehead of 29 middle-aged female volunteers by means of ultrasonography. Fixed wrinkles present when the eyes were closed and wrinkles transiently formed when the eyes were open were evaluated using a photograph-based 6-grade evaluation system for each type of wrinkle. RESULTS: Fat infiltration at the forehead area was observed similarly to that in the cheek area as we reported previously. We found that opening the eyes induced the formation of stable transient wrinkles, the grade of which was significantly related to fat infiltration severity. Furthermore, fat infiltration was also significantly related to the severity of fixed wrinkles. Moreover, the severity of transient wrinkles was significantly related to that of fixed wrinkles. CONCLUSIONS: Our results suggest that fat infiltration into the dermal layer enhances transient wrinkle formation during facial expression by impairing the ability of the skin to resist deformation, thereby promoting fixed wrinkle formation. Therefore, fat infiltration is a critical cause of wrinkle formation.

Three-Dimensional Assessment of Frontal Bossing and Temporal Pinching in Patients with Sagittal Craniosynostosis Using Curvature Analysis.

BACKGROUND: Sagittal craniosynostosis results in varying degrees of frontal bossing and bilateral temporal pinching. This study assessed the three-dimensional changes in these regions using curvature analysis and volumetric analysis before and 1 year after extended sagittal strip craniectomy (ESC) with postoperative helmet therapy. METHODS: A retrospective review of three-dimensional photographs of 50 subjects treated with ESC with postoperative helmet therapy and 50 age-matched controls was performed. Images were collected preoperatively and 1 year postoperatively. Forehead convexity and temple concavity were quantified. Computed tomographic scans of subjects with and without sagittal synostosis were analyzed to assess the percentage of total intracranial volume (ICV) in the anterior cranial fossa before and after ESC with postoperative helmet therapy. RESULTS: Forehead convexity in the ESC with postoperative helmet therapy group preoperatively (24.49 ± 3.16 m -1 ) was significantly greater than controls (22.48 ± 3.84 m -1 ; P = 0.005). Forehead convexity significantly decreased after ESC with postoperative helmet therapy (18.79 ± 2.43 m -1 ; P < 0.001) and did not differ from controls (19.67 ± 3.08 m -1 ; P = 0.115). The ESC group had more concave temples preoperatively (-10.27 ± 4.37 m -1 ) as compared with controls (-6.99 ± 3.55 m -1 ; P < 0.001). Temple concavity significantly decreased after ESC (-4.82 ± 3.17 m -1 ; P < 0.001) and did not differ from controls (-5.64 ± 3.27 m -1 ; P = 0.075). In the ESC group, the percentage ICV in the anterior cranial fossa decreased from 22.03% to 18.99% after surgery, whereas the anterior volume in controls was stable (17.74% to 16.81%). CONCLUSIONS: The ESC group had significantly greater forehead convexity, temple concavity and anterior cranial fossa volume compared with controls. One year after ESC with postoperative helmet therapy, forehead convexity, temple concavity, and percentage ICV in the anterior fossa were comparable to controls. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Sagittal Position of the Upper Incisor in Relation to the Forehead in Peruvian Individuals with Different Skeletal Relationships.

AIM: The aim of this study was to determine the sagittal position of the upper incisor considering Andrews' analysis based on the position of the forehead in Peruvian individuals with different skeletal relationships. MATERIALS AND METHODS: This retrospective, cross-sectional study included 212 lateral head radiographs of Peruvian individuals (males: 85, mean age 21.38 ± 6.88, and females: 127, mean age 21.18 ± 6.95), with different skeletal relationships (Class I group = 96, Class II group = 57, Class III group = 59). The values of the ANB, SNA, SNB angles as well as the forehead anterior limit line (FALL) and goal anterior limit line (GALL) points were identified in the radiographs, and then a vertical line was drawn in each point to determine if the upper incisor was positioned forward (protruded), backward (retruded) or within (adequate) these lines. Two trained and calibrated investigators performed all the measurements. The Chi-square test was used to evaluate associations. A p-value < 0.05 was considered statistically significant. RESULTS: Overall, the sagittal position of the upper incisor showed a significant association with the sagittal skeletal relationship (p = 0.001). The upper incisors showed an adequate position (41.7%), protruded position (56.10%), and retruded position (42.40%), for Class I, II, and III skeletal relationships, respectively, as highest percentages in each Class. Statistical significance was found for females only (p = 0.005). CONCLUSION: Skeletal Class I mainly showed an adequate position of the upper central incisor, whereas for Class II a protruded position was most frequently found, and Class III presented a retruded position. CLINICAL SIGNIFICANCE: Andrews' analysis based on the position of the forehead in Peruvian individuals is a valuable tool for orthodontic diagnosis. How to cite this article: Bazán-Mendoza JR, Arias-Modesto PB, Ruíz-Mora GA, et al. Sagittal Position of the Upper Incisor in Relation to the Forehead in Peruvian Individuals with Different Skeletal Relationships. J Contemp Dent Pract 2023;24(11):821-825.

Early division of the paramedian forehead interpolated flap using cutaneous ultrasound.

BACKGROUND AND OBJECTIVES: The paramedian forehead flap is an interpolated flap, consisting of the transfer of tissue from the forehead region to the nasal area, irrigated by the supratrochlear artery. Traditionally, the vascular pedicle is divided at between 14 and 21 days. However, this time could be overestimated. Our objective is to demonstrate that the paramedian forehead flap can be divided before that set out in the literature and to demonstrate the usefulness of cutaneous ultrasound to determine the optimal time for division. PATIENTS AND METHODS: A prospective observational study, including patients who required nasal defect reconstruction with a paramedian forehead flap, was designed. The inclusion criteria were: nasal tip, dorsum or alar skin defects following oncological surgery, larger than 2 cm. Twelve patients were included. A retrospective cohort was used to perform a cost reduction analysis. RESULTS: The average time to flow, measured by ultrasound, was 6.6 days. The average number of days to division of the pedicle was 6.9 days. No serious complications were reported. CONCLUSIONS: The paramedian forehead flap can be divided before the traditional reported time. Ultrasound is a reliable and cost-effective technique to determine and individualize pedicle division time.

Reevaluation of the Layered Anatomy of the Forehead: Introducing the Subfrontalis Fascia and the Retrofrontalis Fat Compartments.

BACKGROUND: Novel imaging methods have provided new insights into the layered anatomy of the forehead. This study seeks to critically reevaluate the layered anatomy of the forehead by using ultrasound imaging and cadaveric dissection to provide an accurate anatomical description that can be used to guide safer surgical and minimally invasive frontal procedures. METHODS: This study used ultrasound imaging in a sample of 20 volunteers (12 female and eight male volunteers; aged 35.25 ± 4.2 years; body mass index, 24.28 ± 3.5 kg/m2) and cadaveric dissections of 16 body donors (12 female and four male body donors; aged 72.76 ± 9.5 years) to reevaluate the layered anatomy of the forehead. Layer-by-layer dissections and ultrasound-based measurements of the frontal structures guided conclusions. RESULTS: The following layered arrangement was identified: layer 1, skin; layer 2, superficial fatty layer; layer 3, suprafrontalis fascia; layer 4, orbicularis oculi and frontalis muscle (same plane); layer 5, a homogenous layer of fat [preseptal fat (in the upper eyelid), retro-orbicularis fat (deep to the orbicularis oculi muscle), and retro-frontalis fat (deep to the frontalis muscle); layer 6, subfrontalis fascia; layer 7, preperiosteal fat within the prefrontal space in the lower forehead and deep compartments in the upper forehead; and layer 8, periosteum. CONCLUSIONS: The results of this study add to the current understanding of the layered arrangement of the forehead. The combination of ultrasound imaging and cadaveric dissections provided evidence for a continuous fatty layer deep to the frontalis muscle.

Forehead Flap Templates for Nasal Reconstruction Digitally Developed From 2D and 3D Images.

ABSTRACT: The forehead flap is the gold standard procedure for nasal reconstruction to address a partial or complete rhinectomy. Traditionally, the three-dimensional (3D) nasal defect is manually templated intraoperatively to design the two-dimensional (2D) flap shape on intact morphology. In this clinical study, digital preoperative planning is used to template with computer-assisted design and manufacturing. Preoperative digital templates were implemented for 3 representative patients (1 in Supplementary Digital Content, http://links.lww.com/SCS/D60). This includes designs for a hemi-rhinectomy case from 3D mirroring, a partial total rhinectomy case generated from a 3D scan, and a total rhinectomy case generated from a 3D morphable model based on a prepathology 2D photo. Digital unwrapping flattened the patient's 3D nasal geometry designs to 2D skin flap shapes. Finally, the 2D designs were printed as traceable intraoperative templates at a 1:1 scale. This clinical study demonstrates the application of digital 3D preoperative templating to improve workflow for nasal reconstruction.

Treatment of En Coup de Sabre Deformity with Fat Grafting and Demineralized Bone Matrix: A Case Series.

En coup de sabre deformity (ECDS) is a form of localized scleroderma in the frontoparietal region caused by progressive subcutaneous tissue atrophy and bony defect. Although ECDS involves two layers, skin/subcutaneous tissue and bone, the existing literature mainly focuses only on treating the skin/subcutaneous tissue layer. In this case series, we aimed to propose a novel approach that includes the combined use of fat grafting and demineralized bone matrix (DBM). Four patients with ECDS deformity, operated between February 2016 and October 2018, were retrospectively evaluated. All the patients were treated with the novel approach. Patients were evaluated with localized scleroderma scale and computed tomography (CT) scan in the preoperative period and at the annual follow-up. We observed remarkable improvement in the localized scleroderma scale including appearance, palpation, and size scores in all patients at the annual follow-up. CT scans at the annual follow-up revealed new callus formation at the bony defect area in all patients. Reinforcing fat grafting with DBM could promote healing of the bony and skin/subcutaneous tissue defects associated with ECDS.

Is reverse frontal cranioplasty eligible for the correction of both the forehead deformities and the intracranial hypertension in craniosynostosis? Comparison of the preoperative and postoperative intracranial volumes.

BACKGROUND: This study aimed to describe the surgical technique of reverse frontal cranioplasty (RFC), the aesthetical modification as well as the modification of intracranial volume (ICV) to assess its potential eligibility for the treatment of the intracranial hypertension (IH). MATERIALS AND METHODS: A retrospective monocentric study included the patients with a history of craniosynostosis with a forehead deformity who underwent RFC. A subjective outcome questionnaire (SOQ) was conducted with each patient or their parent to determine their level of satisfaction after RFC. Pre- and postoperative computed tomography (CT) scans were analyzed and compared to investigate the ICV change and fronto-nasal angle. RESULTS: Eleven patients were included in the study (6 female and 5 male) with a mean age of 10.9 years old (range 3-23 years) and an average follow-up of 4.5 years (1-11 years). All patients responded to the questionnaire with a high level of overall satisfaction (mean 9.1/10). The mean preoperative FNA was 134° ± 5° while the mean postoperative angle was 126.4° ± 6, corresponding to an average decrease of 7.6° (95% CI, 4.0-11.2°; p < 0.001). One patient with preoperative IH had a clinical recurrence during the follow-up. The ICV was significantly higher after the surgery (p < 0.0001), with an average increase of 3.2% (95% CI, 2.3-4.1%). CONCLUSION: Reverse (RFC) is a useful technique for the correction of the frontal malformations related to craniosynostosis, such as a sloping forehead and/or a lack of the supraorbital projection. Regarding the limited gain of intracranial volume (ICV), it should not be used alone as primary cranial expansion surgery for craniosynostosis with intracranial hypertension (IH).

Relationship of anteroposterior position of maxillary central incisors with the forehead in an adult Iranian subpopulation: A cross-sectional study.

OBJECTIVE: This study aimed to assess the relationship of the anteroposterior position of maxillary central incisors with the forehead in an Iranian subpopulation residing in Kermanshah city. MATERIALS AND METHODS: In this cross-sectional study, 12 orthodontists were requested to analyse full-smile profile photographs with complete maxillary incisor and forehead show in 70 patients with optimal facial harmony (35 males and 35 females) as the control group and 140 patients without optimal facial harmony (70 males and 70 females) as the test group. The inclusion criteria were (I) males and females between 18-60 years seeking orthodontic treatment and (II) willingness for participation in the study. The exclusion criteria were (I) presence of severe craniofacial anomalies, and (II) history of orthodontic treatment. The photographs were traced and analysed using Digimizer Image Analysis software 5.3.5. Data were analysed using STATA version 14.2 via independent t-test and linear regression. RESULTS: A significant difference existed in the anteroposterior position of maxillary incisors in males between the test and control groups (P=0.002). However, this difference was not significant in females of the two groups (P=0.77). A significant difference was noted in the anteroposterior position of maxillary incisors between males and females in the test group (P=0.001) but not in the control group (P=0.80). The frontal angle had a significant correlation with gender and anteroposterior position of maxillary incisors in both groups (P<0.001). CONCLUSIONS: According to the results, the anteroposterior position of maxillary incisors was significantly different in the test and control groups. The maxillary incisors in males were more retruded than in females. Also, the frontal angle had a significant correlation with the anteroposterior position of maxillary incisors, and by 1° increase in the frontal angle, the incisors were protruded by averagely 0.307mm.

The role of near-infrared fluorescence imaging with indocyanine green dye in pedicle division with the paramedian forehead flap.

The paramedian forehead flap is considered the gold standard for nasal reconstruction following oncologic surgery. During the 21-day delay in two-stage surgery protocols, many patients report considerably reduced quality of life because of the pedicle. This prospective case series study examined the usefulness of near-infrared (NIR) fluorescence with indocyanine green (ICG) for flap perfusion assessment and identified variables associated with time to flap perfusion. Ten patients (mean age 75.3 ± 11.6 years) with diagnosis of basal cell carcinoma (n = 9) or squamous cell carcinoma (n = 1) underwent intravenous indocyanine injection and NIR fluorescence imaging for assessment of flap vascularisation 2 to 3 weeks after stage 1 surgery. NIR fluorescence imaging showed 90% to 100% perfusion areas in all patients after 14 to 21 days. Early pedicle division occurred in two patients on postoperative days 14 and 16. One minor complication (wound healing disorder) was seen following flap takedown after 14 days. There were no associations between time to flap perfusion and defect size or flap area. NIR fluorescence imaging with ICG dye is a useful method for non-invasive perfusion assessment when used in conjunction with clinical assessment criteria. However, a decision for early pedicle division may raise risk of complications in specific patient groups and must therefore be made with great care.

The Change of Plane of the Supratrochlear and Supraorbital Arteries in the Forehead-An Ultrasound-Based Investigation.

BACKGROUND: Injecting soft tissue fillers into the deep plane of the forehead carries the risk of injection-related visual compromise due to the specific course of the arterial vasculature. OBJECTIVES: The aim of this study was to investigate the 2- and 3-dimensional location of the change of plane of the deep branch of the supratrochlear and supraorbital artery, respectively. METHODS: A total of 50 patients (11 males and 39 females; mean age, 49.76 [13.8] years, mean body mass index, 22.53 [2.6] kg/m2) were investigated with ultrasound imaging. The total thickness and the distance of the arteries from the skin and bone surface were measured with an 18-MHz broadband compact linear array transducer. RESULTS: The deep branch of the supraorbital artery changed plane from deep to superficial to the frontalis muscle at a mean distance of 13 mm (range, 7.0-19.0 mm) in males and at 14 mm (range, 4.0-24.0 mm) in females and for the deep branch of the supratrochlear artery at a mean distance of 14 mm in males and females (range, 10.0-19.0 in males, 4.0-27.0 in females) when measured from the superior orbital rim. CONCLUSIONS: Based on the ultrasound findings in this study, it seems that the supraperiosteal plane of the upper and lower forehead could be targeted during soft tissue filler injections because the deep branches of both the supraorbital and supratrochlear arteries do not travel within this plane. The superficial plane of the lower forehead, however, should be avoided due to the unpredictability and inconsistent presence of the central and paracentral arteries.

X-linked frontometaphyseal dysplasia with severe scoliosis and spinal cord compromise in an Indian boy.

Frontometaphyseal dysplasia (FMD) is a rare genetic disorder with morphological abnormalities of the skeletal and extra skeletal tissues. It belongs to the group of otopalatodigital spectrum disorders. Here we report a 12-year-old boy from India with features of frontometaphyseal dysplasia who had severe scoliosis with neurological complications due to spinal cord compromise. Clinical examination of his mother also revealed mild features of FMD. The manuscript highlights the clinical presentation of the disorder and discusses the clinical heterogeneity of the otopalatodigital spectrum disorders.