Management of a benign forehead tumor is not difficult except for the problem of conspicuous scarring. These masses are usually excised directly through an incision on the surface of the mass. To avoid an ugly scar, this incision is parallel to the facial expression line and is usually transverse in direction. However, an incision inevitably results in a scar, and sometimes this scar is unacceptable to the patients or their families, regardless of whether it is obvious.
One of the advantages of endoscopic surgery is that an operation can proceed by means of small incisions. In the past decade, application of endoscopic surgery has become rapidly popular in the field of plastic surgery. It has been used for harvesting muscles, nerves, adipofascial flaps, and parotid tumors, in addition to endoscopic facelift. 1–5 Excision of a tumor with endoscopic assistance has also been developed. 6–8 In the current series, removal of forehead and brow benign tumors was assisted with endoscopic surgery. Because the incision was located behind the frontal hairline, there was no scar on the forehead. Patients and their families greatly appreciated this “scarless” operation.
Materials and Methods
From February 1998 to March 2000, 25 patients underwent excision of forehead tumors. All patients requested removal of the tumors without obvious scarring, and refused direct excision after our introduction of the advantages of endoscopic surgery.
Four children underwent the operation under general anesthesia. Adults, however, were treated under local anesthesia. A local anesthetic is injected mainly between the galea and the periosteum. Usually Xylocaine is injected in excessive amounts greater than that required for effective anesthesia, which results in a hydrodissection effect that is helpful for dissection. Only the operating field, which is approximately 5 cm wide from the incision site to the mass, is infiltrated with 1% Xylocaine with 1:200,000 epinephrine. The incision site is selected to permit the shortest distance and easiest access to the mass. A 2.5-cm horizontal or vertical incision is located approximately 2 cm behind the front hairline. Surgical instruments and the endoscope with its mounted retractor are introduced through this incision. For those with tumors located in the middle forehead, the tumor was approached through the subgaleal plane (Figs 1A, B). If the tumor is located in the lateral eyebrow or the temporal area, the dissecting plane is superficial to the deep temporal fascia to prevent injury of the frontal branch of the facial nerve (Figs 2A, B). At first, these masses are not visualized in the dissecting plane because they are usually located in overlying muscular or subcutaneous layers. When the exact location of the mass is ascertained, surrounding tissues including muscle, nerve, and vessels are dissected to free the mass (Figs 1C and 2C). During dissection and excision of the mass, digital pressure is applied to the overlying skin. This pressure pushes the mass downward for easy access, and maintains an opposite force for a firm dissection. Sometimes this external digital pressure is helpful in identifying the location of the mass. With good illumination and magnified monitor viewing, tissues are clearly visualized. The peripheral nerve and vessels can be dissected safely and preserved (Figs 1C, and 2C, D). If the mass is a lipoma, complete excision with an endoforceps or using a long hemostat to remove it piece by piece is relatively easy. If it is a dermoid cyst, the cystic wall of the mass should be dissected and removed completely. Because it is usually difficult to excise a dermoid cyst without rupture, the dermoid content and ruptured cystic wall are removed separately.
The wound was closed primarily without any drain. A firm dressing with an elastic bandage on the forehead is applied for 2 days postoperatively.
In the current series there were 12 female and 13 male patients. Their age ranged from 3 to 59 years. Four patients were children. The masses varied in size from 1.0 × 0.5 to 2.0 × 2.0 cm. In 18 patients the masses were located in the middle forehead. Other locations included the lateral eyebrow (N = 4) and the temporal area (N = 3). Pathology reports of these masses revealed 18 cases of lipoma, 6 cases of dermoid cyst, and 1 case of pilomatricoma. The follow-up period ranged from 1 to 24 months. The postoperative course in all patients was uneventful. There were no residual masses or recurrences. Patients and their families were satisfied with these “scarless” operations (see Figs 1B and 2B).
One concern in the management of forehead or brow tumors is the aesthetic result after operation. Usually the conventional transverse incision leaves a fine scar. To minimize the length of the incision, Vivakananthan 9 removed the dermoid cyst with a puncture wound to pull out the cyst wall and its content. Despite this elaborate manipulation, however, there is still a scar.
With the assistance of endoscopic surgery, Posner and colleagues 6 removed a facial lipoma along the angle of the mandible. Itoh and associates 8 extracted a facial dermoid cyst with endoscopic surgery through two incisions located at the external acoustic meatus. These patients were satisfied with this kind of “scarless” operation. In a study of donor site morbidity, and a comparison between endoscope-assisted and traditional harvest of free latissimus dorsi muscle flaps, Lin and coworkers 10 revealed that the patients’ attitudes and feelings about the scar, and their overall satisfaction were higher in the endoscopic group.
Recently, endoscopic forehead lift has become popular. This operation is accomplished through four to five incisions (2.5 cm in length) in the scalp behind the front hairline. 11 In patients needing a browlift there is a very high percentage (95%) who accept endoscopic forehead lift because of the many advantages that the endoscopic approach offers. 12 Papay and colleagues 7 ablated a tumor of the forehead and brow with endoscopic surgery through two incisions located in the hairy scalp. Postoperative morbidity decreased substantially, in addition to producing more acceptable scars. In the current series only one incision was used to introduce both the endoscope and the surgical instruments. The number of scars caused by the operation was decreased to one in these patients.
Papay and colleagues 7 approached the mass via subperiosteal dissection. Before the mass was located, a small incision was made on the periosteum. The operative field was restricted through this incision and sometimes was not favorable for tumor dissection. In the current series, subgaleal dissection offered a wider operative field and a nearly direct approach to the mass. Excision of the mass was thus easier and quicker than that via the subperiosteal approach. There was a possibility of rupture of the cystic wall during dissection and extraction of the dermoid cyst. If this occurred, its muddy content would spill and stick to the operative field. With or without irrigation with normal saline solution, these spilled materials could be removed by means of suction. In the current series, total excision of the dermoid cyst or lipoma was accomplished with assistance of endoscopic surgery.
Nerve fibers of the supraorbital, supratrochlear, and zygomaticotemporal nerves run vertically through the forehead to the scalp. Any transverse incision on the forehead injures some of these nerve fibers and results in paresthesia or numbness on the scalp behind the incision. The direction of endoscopic dissection is parallel to these fibers, and thus the incidence of nerve injury is reduced. The incidence of nerve injury is decreased further because the endoscope offers good illumination and magnified monitor viewing for clear identification and preservation of any nerve fibers encountered (see Figs 1C and 2C). The operative field was clean and bloodless because the blood vessels were also clearly visualized and preserved. In our patients there were no complications such as paresthesia or numbness.
The drawback of this operation is that it requires expensive endoscopic equipment and a demanding endoscopic surgical technique. However, as endoscopic surgery becomes increasingly common, these problems will be solved.
The advantages of this operation are that there is no scar at the tumor site and there is a low incidence of accidental injury to the neurovascular structures in the forehead, in addition to the other advantages of endoscopic surgery. Endoscope-assisted forehead tumor excision is a good alternative and has great potential in the management of tumors of the forehead and brow.
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© 2001 Lippincott Williams & Wilkins, Inc.
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