Superficial Temporal Artery Island Flap Combined With Laser Hair Removal for Inadequate Skin Expansion Following Tissue Expansion: A Case Report of Congenital Melanocytic Nevus of the Forehead in an Adult

Abstract

Tissue expansion is a handy reconstructive technique for the head and neck region; however, its implementation requires careful planning and surgical experience. If tissue expansion is inadequate, forced closure results in wound tension and risks complications, such as postoperative deformity, wide scarring, and wound dehiscence. We report a case of adult forehead melanocytic nevus excision using a tissue expander (TE) where complications caused by insufficient tissue expansion were avoided by creating a flap using a dog ear. The patient was a male in his 20s who underwent surgery with a TE for a congenital melanocytic nevus sized 15 × 10 cm on the left forehead. Resection was performed by tissue expansion using two TEs; however, simple advancement flaps led to excessive wound tension, risk of elevation of the eyebrow on the affected side, and postoperative scarring. Hence, a superficial temporal artery fasciocutaneous island flap with left superficial temporal vessels as a pedicle was raised at the dog ear and moved to the site of strong tension, and the wound was closed without difficulty. Although postoperative laser hair removal was required, both the appearance and functional results were satisfactory. Using anatomical flaps obtained from the surroundings during tissue expansion helps avoid complications associated with forced wound closure.

Keywords: complications; congenital melanocytic nevus; flap surgery; reconstructive surgery; superficial temporal artery flap; surgical planning; tissue expander; tissue expansion.

Figure 1. Clinical photographs at the time of initial examination

(A) Frontal view: a hairy congenital melanocytic nevus sized 15 × 10 cm is observed on the left forehead beyond the midline and hairline. (B) Oblique view: a scar from a tissue biopsy in childhood is observed in the center of the lesion (red arrowhead)

Figure 2. Photographs before and after the initial surgery

(A) Two rectangular-type TEs (KOKEN, Tokyo, Japan) were inserted. The first TE (290 cc, 100 × 50 × 70 mm) was inserted under the frontalis muscle on the healthy side through a longitudinal incision in the nevus, and the second TE (330 cc, 140 × 70 × 40 mm) was inserted under the epicranial aponeurosis through a hairline incision in the nevus. (B) Clinical photograph after the completion of expansion TE: tissue expander

Figure 3. Intraoperative photographs of the second surgery

TE removal and nevus excision were performed four months after the first surgery and one month after expansion completion. (A) The resection area was set with a horizontal margin of 2 mm from the nevus edge. Part of the nevus was expanded, and the resection area was determined to be 19.5 × 10 cm in size. (B) The excised nevus. (C) STA and its branches were identified using handheld Doppler ultrasound (yellow arrowhead), and the STA island flap was designed at the area of the dog ear caused by the posterior expanded flap advancement. (D) The STA island flap pedicled with STA, concomitant vein, and surrounding temporoparietal fascia was elevated and moved to the forehead. (E) Lateral view immediately after the surgery. The STA flap placement allowed all sutures to be placed without excess tension. (F) Frontal view immediately after the surgery. The flap allowed wound closure without elevation of the eyebrows TE: tissue expander; STA: superficial temporal artery

Figure 4. Clinical photographs at six months after nevus excision

(A) Frontal view. (B) Oblique view

Figure 5. Clinical photograph at 18 months after nevus resection

A scar revision operation and laser hair removal with an 810-nm diode laser were conducted. The scar was relatively unnoticeable and the patient was satisfied with the results. (A) Frontal view. (B) Oblique view