The forehead presents unique challenges and opportunities to the surgeon. The convex surface may increase the tendency toward dog-ear formation, as even ellipses with large length-to-width ratios may result in a residual standing cone appearance.
Additionally, the relatively immobile skin and minimal laxity coupled with the nearby presence of the eyebrows may also translate into a risk of long-standing brow asymmetry in select cases. While this is generally addressed when designing the closure, suture technique may play a role here as well.
The natural furrows and wrinkles present, particularly on the muscular forehead of elderly men, also need to be considered when designing forehead closures and when choosing suture techniques, as blunting a dramatic wrinkle may draw attention toward an otherwise well-designed repair. In such cases, an inverting technique may be preferable. Conversely, patients treated with neurotoxins to mitigate the appearance of forehead wrinkles may benefit from everting techniques that will leave only barely perceptible scars as they heal.
As always, linear closures are preferable to flap and graft techniques whenever possible. Often, such closures are directed transversely across the forehead, so that the suture line remains hidden in the natural lines and wrinkles. This must also be weighed against the risk of causing an asymmetrical brow lift. Suture techniques directed at fixing the lower portion of the repair in place or maximally mobilizing the upper portion of the repair, such as suspension sutures, may be useful in these situations. Occasionally, however, especially with medially located defects, causing a subtle brow lift may be desirable.
For larger defects on the forehead, vertically oriented repairs may be useful as well. As with paramedian forehead flaps, a full-thickness incision and subgaleal undermining may be used to further mobilize tissue and to permit a straightforward linear closure.
For mild- to moderate-tension closures on the forehead, 5-0 absorbable suture is generally sufficient. Using a small needle, such as the P-3 reverse cutting needle, is often adequate. For wounds under greater tension, 4-0 absorbable suture material may be used as well, particularly if a deep incision has been made and the wound is being closed with plication or deep soft tissue sutures. Fine-gauge 6-0 or 7-0 nonabsorbable suture material may be used for transepidermal sutures.
As with most closures on the face, workhorse techniques such as the set-back dermal suture and the buried vertical mattress suture are the usual approaches of choice (Figure 6-6).
Frequently used suturing techniques on the forehead.
As briefly noted earlier, an important exception to this approach would be utilizing inverting techniques when attempting to hide a closure within pronounced skin folds or wrinkles on the forehead. This ...