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IDEAS AND INNOVATIONS

Endoscopic Approach for the Resection of Forehead Masses

Cronin, Ernest D. M.D.; Ruiz-Razura, Amado M.D.; Livingston, Christopher K. M.D.; Katzen, J. Timothy M.D.

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Plastic and Reconstructive Surgery: June 2000 - Volume 105 - Issue 7 - p 2459-2463
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The classic surgical approach to a forehead mass is simple direct excision. However, patients may not always be willing to accept the risk of a prominent forehead scar. Direct excision can produce a noticeable scar for a variety of reasons: a patient with a smooth forehead without many frown lines, a large mass necessitating an equally large incision, poor wound healing, predisposition to skin pigment changes, or an exaggerated healing response with hypertrophic scarring, or worse, keloid formation. \. Over the past several years, surgery aided by the endoscope has come into favor for a number of reasons. Because it is minimally invasive surgery, it has less morbidity, thus reduced postoperative pain and complications; it results in earlier mobilization and shorter hospitalization, and most importantly it contributes to an improved cosmetic appearance as a result of a shortened incision line concealed within the hairline in most cases. {altfoot}From the Plastic Surgery Service, Christus St. Joseph Hospital. Received for publication June 28, 1999; revised October 14, 1999.

The use of the endoscope in plastic surgery is not a new technique; augmentation mammaplasty, implant evaluation, and carpal tunnel release have all been safely performed by using the endoscope. Now there are increasing reports of its surgical applications in the craniomaxillofacial region, including endoscopic face lift, forehead lifts, frontal sinus operation, rhinoplasty, and mandibular osteotomy. 1 Previous case reports have mentioned the use of the endoscope to resect a sphenoethmoid osteoma and forehead osteomas. 1 In addition, there have been two recent reports of endoscopic excision of forehead masses in adult as well as pediatric patients. 2,3

As plastic and reconstructive surgeons continue to test the limits of video assisted endoscopic surgery, more procedures will be safely and easily performed with the endoscope; thus, we propose an alternative approach to the surgical resection of forehead masses. We have found the endoscope to be useful not only for diagnosis but also as a therapeutic tool for the removal of these forehead lesions. Our purpose is to describe the clinical experience with the removal of forehead masses in four patients.

Case Reports

Case 1

A 26-year-old African-American woman presented with a 2 × 2 cm mass on her forehead, which had increased slowly in size over the past several years. The mass was located approximately 3.0 cm above the medial aspect of her right eyebrow. Her medical history was unremarkable, except for her propensity for keloid formation. In addition, she denied any trauma to her forehead or familial occurrence of skin lesions. Physical examination revealed a dome-shaped mass that was soft, mobile, and nontender, consistent with a lipoma. She desired this lesion to be removed, but was reluctant because of previous keloid formations. Accordingly, she refused the conventional forehead incision.

Case 2

A 55-year-old white man presented with a 2.5 × 3 cm mass on his forehead that had been present for many years and had recently increased in size. His medical history was unremarkable, and he denied any trauma to the site or familial occurrence of skin lesions. Physical examination revealed a soft, mobile, and nontender mass without skin surface discoloration. These findings were consistent with a lipoma. He wished to have this mass removed; however, he was concerned with facial scarring. Thus, he refused a forehead incision, which could have become somewhat prominent because of his smooth, noncorrugated forehead.

Case 3

A 57-year-old African-American woman presented with several indolent masses throughout her forehead. Physical examination revealed a fleshy and soft, mobile mass located centrally on her forehead measuring 1 × 1 cm. There were several harder and more immobile masses located above her left eyebrow with the largest measuring 1 × 1 cm (Fig. 1). None of these masses were painful. Clinically, the fleshy mass was consistent with a lipoma, whereas the more firm masses were consistent with osteoid osteomas. Her medical history was unremarkable, and she denied any trauma to her forehead or familial occurrence of skin lesions. She wished to have these masses removed, but she wanted her scars well hidden.

Fig. 1
Fig. 1:
(Case 3) A 57-year-old African-American woman with multiple, slow-growing forehead masses. She was reluctant to have them removed for fear of visible forehead scars. Upon physical examination, the midline mass was consistent with a lipoma, whereas the more lateral masses were consistent with osteoid osteomas.

Case 4

A 50-year-old African-American woman presented with a solitary soft and fleshy mass located above her right eyebrow. Physical examination revealed a nontender and mobile mass measuring 2 × 3 cm, which was consistent with either an epidermal incision cyst or a sebaceous cyst caused by her oily skin. It had increased in size over the past 6 months, and she wished the mass to be removed without a visible scar. Her medical history was unremarkable. She denied any trauma to the area, recent acne, or any familial occurrence of skin lesions.

Materials and Methods

All clinical cases were performed with full written consent and explicit explanation of procedures. In addition, patients were informed that conversion to an open technique might be necessary.

A standard video system consisting of a three-chip endoscopic camera, xenon light source, television monitor, and video recorder with color printer was used for each procedure. Instrumentation included a 4.0-mm 0-degree arthroscope, several endoscopic instruments, retractors, and periosteal elevators.

Operative Procedure

The operations were performed either under local anesthesia with intravenous sedation or under general anesthesia. Cases 1 and 3 were performed under general anesthesia; case 2 was performed under intravenous sedation, whereas case 4 was completed by using only local anesthesia, similar to that described by Kokoska et al. 2 All patients received local infiltration with a solution containing lidocaine (1%) and epinephrine (1:100,000).

Two separate 1-cm incisions were made in the scalp. The first was in the midline and posterior to the anterior hairline. The second, and more lateral, incision was 1 cm posterior to the temporal hairline (Fig. 2). To minimize the potential for postoperative alopecia, the incisions were created parallel to the long axis of the hair follicles. An ultra-fine electrocautery tip was used to minimize bleeding. Each scalp incision was deepened to the periosteum and subperiosteal dissection was continued to the level of the lesion. In some cases, dissection was extensive (in case 3, the mass was 10 cm from the scalp entry site). Once subperiosteal dissection was completed, the endoscope was introduced and a grasper was inserted into the lateral scalp incision. Although endoscopic equipment was always directly visualized inside the pocket, location on the skin surface was performed by manual palpation and external visualization. This served two purposes, first, judging distance to the mass and second, avoiding skin breakthrough and injury to overlying nerves.

Fig. 2
Fig. 2:
Two separate 1-cm incisions were made in the scalp. The first was in the midline and posterior to the anterior hairline. The second and more lateral incision was 1 cm posterior to the temporal hairline. To minimize the potential for postoperative alopecia, the incisions were created parallel to the long axis of hair follicles.

Under direct endoscopic vision, it was noted that the lipoma lesions developed superior to the galea level (cases 1, 2, and 3). Thus, the galea aponeurosis was incised and the lipomas were dissected free on all sides with endoscopic scissors and an endoscopic probe. With clear endoscopic visualization, each lipoma was mobilized easily and removed en bloc with a grasper. In addition, care was taken to avoid damage to the supraorbital and supratrochlear neurovascular bundles. After the lipomas were extracted, the subcutaneous space was irrigated with an antibiotic-impregnated saline solution.

In addition to the lipoma removed in case 3, four osteomas were encountered. To remove these bony lesions, a straight bone chisel was inserted and the osteomas were excised in a piecemeal manner. Small imperfections of the surrounding cranial surface were flattened and smoothed with a bone rasp. After removal, the wound was irrigated with aseptic saline.

In case 4, a sebaceous cyst was identified in the subcutaneous tissue. This cyst was removed without disturbing the capsule in a similar technique as described for lipoma removal. The wound was again generously irrigated with an antibiotic-impregnated saline solution.

After careful endoscopic inspection to confirm hemostasis and the absence of residual mass, the endoscope was removed. Subsequently, to remove air and especially blood from the subperiosteal cavity, external pressure was applied in a rolling manner from the orbital rim to the two scalp incisions. In all cases, the skin incisions were closed primarily with interrupted 4-0 Prolene. General anesthesia (cases 1 and 3) and intravenous sedation (case 2) were discontinued. All patients were then transferred to a recovery room. A sterile head wrap was applied for 3 days, and the removed specimens were sent to pathology for definitive diagnosis.

Results

Endoscopy was performed on four patients with forehead masses. Between one and two lipomas were removed in cases 1, 2, and 3 (Fig. 3). Four osteoid osteomas were extracted in case 3, whereas a solitary sebaceous cyst was removed in case 4.

Fig. 3
Fig. 3:
The endoscope provides direct and magnified visualization, allowing easy access for accurate tissue biopsy or mass removal. It was noted that the lipoma lesions developed superior to the galea level (cases 1, 2, and 3). The galea aponeuroses was incised, and the lipomas were dissected free on all sides with endoscopic scissors and an endoscopic probe.

All masses were completely excised by using endoscopic assistance, through two 1-cm incisions. Intraoperatively, there were no surgical or anesthetic complications. To date, postoperative course has been uneventful. Short- and long-term follow-up have revealed no complications and no recurrences. Specifically, there have been no hematomas, signs of nerve damage, vascular injuries, infections, or signs of alopecia. Every incision has healed adequately, and all are well hidden behind the anterior hair line. The visible forehead was completely free of any scar, yielding not only a very satisfied patient, but an excellent cosmetic result (Fig. 4). Permanent sections of all masses extracted revealed no signs of malignancy.

Fig. 4
Fig. 4:
Immediately postoperative with masses completely excised. The visible forehead was completely free of any scar, yielding not only a very satisfied patient but an excellent cosmetic result.

Discussion

Endoscopic procedures are now routine in most plastic and reconstructive surgeons’ practice. In addition, reports have shown that a variety of acquired or congenital defects of the forehead can be corrected with the endoscope. 4,5

We propose that the endoscope should be used routinely to evaluate, diagnose, and remove forehead masses in the following situations: (1) a mobile and soft mass, (2) patients with a propensity for keloid formation or hypertrophic scarring, (3) patients with smooth foreheads, and (4) patients extremely wary and conscious of any residual forehead scar. Thus, endoscopic removal of forehead masses is yet another safe and effective procedure that should become a therapeutic option for any surgeon whose patient requests a more esthetically pleasing result.

In the present prospective study, four patients with a variety of forehead masses were evaluated. Three lipomas, four osteomas, and one sebaceous cyst were removed endoscopically without complications.

The advantages of forehead endoscopy are multiple. The procedure is safe and is relatively easy to perform. The endoscope provides direct and magnified visualization allowing easy access for accurate tissue biopsy or mass removal. One of the advantages of using the endoscope in this particular setting is to decrease the chances of neuroma and pain after deep incisions to the forehead, which is not uncommon because some of the sensory nerves of the forehead are transected with the open technique. There has been a decreased incidence of infection in patients undergoing endoscopic procedures. 10 Furthermore, dissection under direct endoscopic visualization has been noted to decrease the incidence of postoperative hematomas, 10 and incisional scars are small and hidden behind the hairline. However, it should be noted that in young males whose hairlines may change with age, the incision should be placed more posterior. 2

In addition, endoscopy excision reduces postoperative pain, shortens hospital stays, and diminishes periods of disability. 10 If necessary, it can be combined with other endoscopic procedures, such as foreheadplasty, rhytidectomy, rhinoplasty, otoplasty, etc. Thus, patients are more willing to undergo an endoscopic procedure rather than direct excision; postoperatively, patients are extremely satisfied.

Disadvantages are few. Complications associated with forehead endoscopy are similar to those described for any endoscopic procedure, i.e., neurosensory damage, vascular injury, excessive operating time, and a sense of tediousness. However, as with any new technique, with proper training and practice, the plastic surgeon can only improve.

Indeed, operative time is initially longer, but there is a steep learning curve and times will dramatically shorten after the first five or 10 procedures. In fact, Paige et al. reported the average duration of endoscopic procedure to be 46.9 minutes in their pediatric subgroup. They reported an incision length of 1.1 cm, high parent satisfaction, and no significant complications. 3

Likewise, expense is always an issue. However, most hospitals already possess endoscopic equipment or with minimal modifications, the general laparoscopic equipment can be adapted for this minimally invasive procedure. Eventually, overall cost should be less than that of the conventional technique because of shorter operative times and outpatient status.

Although our diagnoses were accurate preoperatively and perioperatively, it is possible to encounter unpredicted pathology at the time of surgical exploration. The differential diagnosis of forehead masses includes lipomas, osteomas, sebaceous cysts, hemangiomas, and a variety of malignant tumors. Should the mass prove to be extensive or malignant, or if the diagnosis is incorrect and, thus, a more extensive operation is necessary, the procedure can be converted to open without difficulty. 11 Likewise, should the lesion be larger than expected, one incision can be enlarged to accommodate the mass and still yield a cosmetically acceptable scar.

With the current elevated enthusiasm for newer minimally invasive procedures, plastic surgeons must not lose sight of ongoing studies to evaluate the efficacy, indications, contraindications, patient selection, complications, and long-term risks and benefits to the patient. These cases illustrate the feasibility and ease of resecting a variety of forehead masses with excellent cosmetic results.

Summary

Over the past several years, surgery aided by the endoscope has come into favor for a number of reasons. Because it is minimally invasive surgery, it has less morbidity, thus, reduced postoperative pain and complications. It results in earlier mobilization and shorter hospitalization, and most importantly, it contributes to an improved cosmetic appearance as a result of a shortened incision line concealed within the hairline in most cases. We have proposed an alternative approach to the surgical resection of forehead masses by means of the endoscope, which has proven to be useful not only for diagnosis but also as a therapeutic tool for the removal of forehead lesions. This report described the clinical experience with the removal of forehead masses in four patients. The cases illustrated the feasibility and ease of resecting a variety of forehead masses with excellent cosmetic results. We hope that more plastic surgeons will use the proposed technique and will continue to explore the safe limits of endoscopic plastic surgery.

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