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Eyebrow Reconstruction Using a Composite Skin Graft from Sideburns

Matsuda, Ken MD, PhD*; Shibata, Minoru MD, PhD*; Kanazawa, Shigeyuki MD, PhD; Kubo, Tateki MD, PhD; Hosokawa, Ko MD, PhD

Plastic and Reconstructive Surgery – Global Open: January 2015 - Volume 3 - Issue 1 - p e290
doi: 10.1097/GOX.0000000000000264
Ideas and Innovations

Summary: Wide resection of malignant skin tumors in the upper orbital region often results in soft-tissue defects involving the eyebrow. We used composite skin grafts from the area around the sideburns for 1-stage reconstruction of skin and eyebrow defects. The results were aesthetically satisfying because the hair and shape of these regions were similar to those of the original eyebrow, and donor-site closure was easy with inconspicuous scar. The survival of full-thickness skin graft area of composite grafts from sideburn facilitates revascularization of thicker hair follicles in the graft and allows safe, natural eyebrow reconstruction.

Supplemental Digital Content is available in the text.

From the *Division of Plastic and Reconstructive Surgery, Niigata University Graduate School of Medicine, Niigata, Japan; and Department of Plastic and Reconstructive Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.

Received for publication October 19, 2014; accepted November 24, 2014.

Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.

Supplemental digital content is available for this article. Clickable URL citations appear in the text.

Ken Matsuda, MD, PhD, Division of Plastic and Reconstructive Surgery, Niigata University Graduate School of Medicine, 1–757, Asahimachi-Dori, Chuo-ku, Niigata 951–8510, Japan, E-mail:

This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

Reconstruction of soft-tissue defects involving the eyebrow requires careful attention to achieve cosmetically satisfactory results. We used composite skin grafts harvested from sideburns for simultaneous reconstruction of the eyebrow and an associated skin defect. Grafts from sideburn areas can convey intermediate hair, which is suitable for eyebrow reconstruction. In addition, the grafts can include preauricular and/or cheek skin, the color and texture of which is a good match for reconstructing the eyebrow region. The angle between hair shafts and skin is sharp in sideburns and closely simulates that of the eyebrow.

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The eyebrow and associated skin defect are partially closed to minimize graft size. This is done with great care, to avoid leaving a significant deformity in the forehead and upper eyelid. The graft is then carefully designed at the donor site (Fig. 1). Graft design relies on 2 principles. First, in eyebrows, the direction of follicles is typically superolateral in the medial and inferior regions and inferolateral in the lateral and superior regions.1 By contrast, hair stream is predominantly in the inferior direction in sideburns. After noting the characteristics of hair stream, the graft is harvested. The other principle is assessment of skin thickness. The suprabrow and infrabrow regions substantially differ in dermis thickness. In addition, preauricular skin is thin, but cheek skin is thick. Graft thickness must be adjusted to match that of the defect. When hair stream and skin thickness are considered, a graft from the contralateral side seems most suitable. However, the donor site should be located as posteriorly as possible. If mainly preauricular skin is harvested, cheek skin can be preserved and the donor-site scar will be inconspicuous. Thus, we prefer to harvest grafts from the contralateral side for reconstructing defects that mainly involve the infrabrow area and grafts from the ipsilateral side for suprabrow defects. After graft harvesting, the subcutaneous fat of the non–hair-bearing area is removed, after which the galea and subcutaneous tissue are removed in the hair-bearing area, which keeps hair follicles intact. The donor site of the graft is then primarily closed.

Fig. 1

Fig. 1

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Case 1

A 64-year-old woman with basal cell carcinoma involving the right eyebrow underwent wide resection, resulting in a 22 × 19 mm defect at the lateral one third of the eyebrow. The lateral area of the defect was partly closed, and a composite skin graft was harvested from the ipsilateral side. The postoperative course was uneventful, and the graft survived completely. Fifteen months after surgery, the graft is well matched to the defect, with aesthetically satisfying results (Fig. 2).

Fig. 2

Fig. 2

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Case 2

An 82-year-old woman with a squamous cell carcinoma involving the right eyebrow area underwent wide resection, resulting in a 47 × 40 mm defect at the lateral half of the eyebrow. The lateral area of the defect was partly closed, and a composite skin graft was harvested from the ipsilateral sideburn. The donor site was primarily closed. Her postoperative course was uneventful, and the graft survived completely. Eighteen months after surgery, the graft is well matched to the defect and has an eyebrow-like appearance (Fig. 3).

Fig. 3

Fig. 3

This method was used in another case. (See Figure, Supplemental Digital Content 1, which displays an 86-year-old woman with squamous cell carcinoma involving the left eyebrow who underwent wide resection, resulting in a 45 × 35 mm defect at the lateral two thirds of the eyebrow (left),

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Methods of eyebrow reconstruction include local flaps, pedicled flaps, and hair transplantation. For relatively small defects, local flaps including the remaining eyebrow2,3 can yield good results; however, large defects require a scalp flap or secondary hair follicle graft. Because eyebrow hair is short and of a small diameter, use of pedicled scalp flaps4 can result in a “brush-like” appearance, as the hair is much denser and thicker than that of the original eyebrow. Although this might be acceptable for men, it is not suitable for women5; however, the use of intermediate hair6 or postoperative laser treatment7 might address this problem.

The use of a free composite graft from the scalp might be a good option for transferring a substantial number of hair follicles in a 1-stage operation. However, because the success of this procedure depends on the vascularity of the recipient site, it is not suitable for all patients. Follicular hair transplantation is more reliable and maintains a natural appearance in the reconstructed eyebrow8; however, this procedure requires multiple stages.

Composite skin grafting is itself not a new technique. It was already being used in the 1960s9 for reconstructing eyebrow and upper eyelid defects. The advantage of composite skin grafting is that it reestablishes the numerous vascular connections between the rete arteriosum cutaneum and the arterior plexus around the hair follicles. The taking of a full-thickness skin graft area leads to increased graft vascularity, which increases the survival of transplanted hair follicles (Fig. 4). We used grafts comprising sideburn hair with preauricular and cheek skin instead of nape hair with retroauricular skin.9 The thinness of the hair, the sharp angle between the hair shafts, and the skin in sideburns closely mimic the characteristics of the original eyebrow. The grafts harvested from sideburns are suitable to reconstruct the multiple natural hairline borders because sideburns contain anterior, posterior, and inferior hairline borders within a narrow area, which is quite useful for reconstructing the natural inferior, superior, and lateral borders of the eyebrow. Because composite skin grafting has cosmetic disadvantage to local flaps including the remaining eyebrow, it should be indicated for larger defects for which the local flaps are difficult to be used, especially including the lateral border of the eyebrow.

Fig. 4

Fig. 4

Our technique is mainly for patients with malignant skin neoplasms, most patients are relatively old. Preauricular skin is looser during old age, which simplifies primary closure of the donor site.

Our results indicate that composite skin grafting from the sideburn area is a useful option for 1-stage reconstruction of large skin defects involving the eyebrow.

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Composite skin grafting from the sideburn area yielded satisfactory results in natural eyebrow reconstruction and allowed easy donor-site closure. The take of full-thickness skin grafts enhanced survival of hair follicles, which enabled safe eyebrow reconstruction.

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Patients provided written consent for the use of their image.

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