Redefining Forehead Reconstruction: Functional and Esthetic Outcomes Using a Preexpanded Brachial Artery Perforator Flap.

Abstract

<h4>Background</h4>Repairing large forehead defects presents significant challenges due to the risk of asymmetry, inconsistent skin color, texture, thickness, or scarring. This study aimed to introduce a method utilizing preexpanded brachial artery perforator (BAP) flaps to reconstruct large forehead defects.<h4>Methods</h4>A retrospective case series was conducted on 17 patients who underwent forehead reconstruction using preexpanded BAP flaps between 2012 and 2024. The etiologies included nevus, scars, neurofibromas, and wounds with titanium mesh exposure. The surgery was performed in 3 stages. An expander was inserted into the medial arm. After achieving adequate inflation, the distally based BAP flap was elevated and transferred to reconstruct the forehead defect. The distal portion of the flap covered the defect, while the proximal portion was rolled into a tube. The pedicle was divided 3 weeks later, and the remaining flaps were reimplanted at the forehead and donor site.<h4>Results</h4>All flaps survived without any perfusion-related complications. The defect location included the unilateral forehead in 13 patients, the central forehead in 3, and the total forehead in one. Defect sizes ranged from 8×5 to 15×7 cm2. Flap sizes ranged from 17×6 to 30×10 cm2, with an average length-to-width ratio of 2.45. Eight patients underwent secondary scar revision, flap debulking, or eyebrow-lifting surgery. No expander-related complications, titanium exposure, wound infections, or shoulder function compromise were observed. After 6 to 80 months of follow-up, flap color, texture, and thickness closely matched the native forehead skin, and the donor-site scar was well concealed within the medial arm. All patients and their families were satisfied with the outcomes.<h4>Conclusions</h4>The distally based BAP flap is an alternative option for reconstructing large or complex forehead defects, providing favorable functional and esthetic outcomes. Future research should explore the survival mechanism of extended BAP flaps.