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OBJECTIVE: The current study aims to investigate the safety and efficacy of using calcium hydroxyapatite (CaHA) versus CaHA associated with hyaluronic acid (HA) for forehead volume replacement and contour restoration without forehead irregularities. METHODS: This interventional study involved 132 participants in a two-arm, parallel, double-blind trial for forehead treatment using the supraperiosteal technique. Group A received CaHA, and Group B received a combination of CaHA and HA as filler materials. Follow-up assessments occurred at 30 and 180 days, incorporating the 5-point Global Aesthetic Improvement Scale (GAIS) and photographic analysis for forehead volume replacement, contour restoration, and without forehead irregularities. Safety assessments included monitoring adverse events, particularly nodules. RESULTS: The study included all 132 enrolled patients who completed the trial. Applying CaHA in combination with HA resulted in a statistically significant improvement in both GAIS scale scores and the reduction of forehead irregularities. The total incidence of nodules was 3.7%. Group A had four times more occurrences of nodules than Group B. Furthermore, Group B exhibited lower rates of forehead irregularities following the treatment compared to Group A. CONCLUSION: The supraperiosteal application of CaHA and HA for forehead treatment demonstrates superior efficacy in addressing signs of aging compared to the isolated use of CaHA.

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BACKGROUND: Recent research introduced the concept of the "line of convergence" as a guide for injectors to enhance precision and avoid complications when treating the frontalis muscle with toxins. However, currently, no pre-injection ultrasound scanning is employed to increase precision and reduce adverse events when searching for the line of convergence. OBJECTIVE: To explore the feasibility and practicality of implementing pre-injection ultrasound scanning into aesthetic neuromodulator treatments of the forehead. METHODS: The sample of this study consisted of n = 55 volunteers (42 females and 13 males), with a mean age of 42.24 (10.3) years and a mean BMI of 25.07 (4.0) kg/m2. High-frequency ultrasound imaging was utilized to measure the thickness, length, and contractility of the frontal soft tissue and to determine the precise location of the line of convergence during maximal frontalis muscle contraction. RESULTS: The results revealed that the line of convergence was located at 58.43% (8.7) of the total forehead height above the superior border of the eyebrow cilia without a statistically significant difference between sex, age, or BMI. With frontalis muscle contraction, the forehead shortens in males by 25.90% (6.5), whereas in females it shortens only by 21.74% (5.1), with p < 0.001 for sex differences. CONCLUSION: This study demonstrated the feasibility and practicality of pre-injection ultrasound scanning for facial aesthetic neuromodulator treatments. Knowing the location of the line of convergence, injectors can determine precisely and on an individual basis where to administer the neuromodulator deep or superficial or when the injection location is at risk to cause eyebrow ptosis.

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AIM: The aim of this study was to determine the sagittal position of the upper incisor considering Andrews' analysis based on the position of the forehead in Peruvian individuals with different skeletal relationships. MATERIALS AND METHODS: This retrospective, cross-sectional study included 212 lateral head radiographs of Peruvian individuals (males: 85, mean age 21.38 ± 6.88, and females: 127, mean age 21.18 ± 6.95), with different skeletal relationships (Class I group = 96, Class II group = 57, Class III group = 59). The values of the ANB, SNA, SNB angles as well as the forehead anterior limit line (FALL) and goal anterior limit line (GALL) points were identified in the radiographs, and then a vertical line was drawn in each point to determine if the upper incisor was positioned forward (protruded), backward (retruded) or within (adequate) these lines. Two trained and calibrated investigators performed all the measurements. The Chi-square test was used to evaluate associations. A p-value < 0.05 was considered statistically significant. RESULTS: Overall, the sagittal position of the upper incisor showed a significant association with the sagittal skeletal relationship (p = 0.001). The upper incisors showed an adequate position (41.7%), protruded position (56.10%), and retruded position (42.40%), for Class I, II, and III skeletal relationships, respectively, as highest percentages in each Class. Statistical significance was found for females only (p = 0.005). CONCLUSION: Skeletal Class I mainly showed an adequate position of the upper central incisor, whereas for Class II a protruded position was most frequently found, and Class III presented a retruded position. CLINICAL SIGNIFICANCE: Andrews' analysis based on the position of the forehead in Peruvian individuals is a valuable tool for orthodontic diagnosis. How to cite this article: Bazán-Mendoza JR, Arias-Modesto PB, Ruíz-Mora GA, et al. Sagittal Position of the Upper Incisor in Relation to the Forehead in Peruvian Individuals with Different Skeletal Relationships. J Contemp Dent Pract 2023;24(11):821-825.

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Pott's Puffy tumor, also called Pott's edematous tumor (PET), is a subperiosteal abscess of the frontal bone, associated with osteomyelitis of the frontal bone. In this paper, we report the case of a 16-year-old patient who presented with headache associated with progressive forehead swelling and fever. Clinical and imaging exams pointed to the hypothesis of PET associated with brain abscess. Patient was submitted to surgical excision of the abscess and treatment of osteomyelitis, with intraoperative findings corroborating the condition. There was a good clinical-radiological recovery associated with prolonged antibiotic therapy and satisfactory follow-up after hospital. PET, which often results from an underdiagnosed or partially treated frontal sinusitis, is a condition that must be promptly recognized and directed to an adequate therapeutic approach due to the risk of serious complications that it entails.

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BACKGROUND: An increasing demand of minimally-invasive aesthetic procedures of the forehead concomitantly leads to higher numbers of adverse events. Adequate application of anatomical knowledge is required to increase safety and efficacy of different minimally-invasive aesthetic procedures in this anatomical region. OBJECTIVE: To describe the layered anatomy of the forehead soft tissues with respect to their thicknesses and how they relate to different minimally-invasive aesthetic treatments. METHODS: A total of n = 85 healthy study participants (69 females and 16 males) with a mean age of 40.84 ± 10.9 years and a mean body mass index of 22.65 ± 2.6 kg/m2 were investigated with ultrasound-based imaging to measure the thickness of different forehead soft tissues. RESULTS: The mean overall soft tissue thickness of the forehead was measured to be 4.18 ± 0.7 mm for the entire study population. Increasing BMI values correlated statistically significantly with increasing thickness of all measured forehead soft tissues with exception of the frontalis muscle. On a statistically significant level, males showed thicker forehead soft tissues than females, with exception of the retrofrontalis fat and the frontalis muscle. CONCLUSION: On basis of the findings obtained in this study, basic treatment principles can be derived and improved for the injection of neuromodulators, hyaluronic acid as well as the application of polydiaxonane (PDO) threads and micro-focused ultrasound. Precise knowledge and thorough understanding of the layers and soft tissues of the forehead is required to guarantee safe and effective procedures in this aesthetically important facial region.

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BACKGROUND: Despite mainly benign, exophytic subcutaneous cranial masses present with a myriad of differential diagnosis possibilities, ranging from simple, superficial lesions to complex lesions involving the central nervous system. Although the gold standard imaging modality for the diagnosis of these lesions is magnetic resonance imaging, Doppler Ultrasonography can be a useful, inexpensive, and available tool for evaluation of lesions that could potentially be safely treated in the primary care setting, and lesions that would demand advanced neurosurgical care. CASE DESCRIPTION: This patient presented with a complex exophytic plasmocytoma that was first diagnosed and erroneously approached as a subcutaneous lipoma with surgical resection in an outpatient surgical setting. This interpretive approach resulted in the failure of the procedure due to significant hemorrhage. The patient was immediately referred to neurosurgical care and transferred to our center. Admission doppler ultrasound imaging revealed absence of the frontal bone, the enriched and profuse vascularization, allowing further and proper diagnostic approach and treatment. CONCLUSION: Ultrasound could be a reliable, fast, and simple imaging method aiding practitioners to perform a better workup for patients with exophytic subcutaneous cranial masses.

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BACKGROUND: A new hyaluronic acid (HA) was appraised to improve forehead horizontal lines (FHL). Histological analysis correlated the gel distribution with clinical findings and also with wrinkle depth, 48 h and 12 months after HA application. METHODS: The new filler composed by 24 mg/ml of HA cross-linked with BDDE 2.0 ppm was injected into the subcutaneous fat, just beneath the dermis, through a retrograde backflow injection technique applied in sequence. Biopsies were taken with a 3.0-mm-diameter skin punch before HA application, 48 h and 12 months after HA application for histological evaluation. RESULTS: Subcutaneous application created a compact cylindrical filament as pattern of gel distribution, which acted as strut raising the FHL to the level of the surrounding tissues. Diameter average of the filament 48 h after HA application was 1.18 mm and at month twelve 0.34 mm. The residual amount of the gel at month twelve ensured the long acting of the HA into the subcutaneous fat. FHL depth of 251.83 µm before HA application and 190.20 µm after 12 months indicated that the residual amount of gel at month twelve still projected FHL. CONCLUSION: High cohesivity of HA and low density of forehead subcutaneous fat caused the gel to take the form of a compact cylindrical filament. The small amount of gel still presenting into the subcutaneous fat 12 months after application validated the long acting of the HA. Evidence-based analysis showed that this new filler might be considered a safe alternative for improvement in the FHL. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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RESUMEN Introducción: El tratamiento ortodóntico tiene como objetivos fundamentales el logro de relaciones oclusales estables y la mejora en la expresión de la sonrisa. Particularmente, la posición de los incisivos centrales superiores presenta un rol importante en esta expresión y se ha sugerido el uso de referencias extracraneales para su correcta posición tridimensional. Conocer las preferencias de los distintos actores sociales respecto a este factor puede ayudar a las decisiones en la planificación de los tratamientos. Objetivo: Evaluar la percepción estética que ortodoncistas, cirujanos dentistas y personas no expertas tienen de la sonrisa con el incisivo central superior en posición anteroposterior respecto a la frente y en norma lateral. Métodos: Se empleó una fotografía en norma lateral en sonrisa de una mujer peruana con perfil normal y posición anteroposterior del incisivo central superior ideal según el elemento II de la armonía orofacial de Andrews. La fotografía fue modificada digitalmente de tal forma que se obtuvieron imágenes con los incisivos retruídos (- 4 mm) y protruidos (+ 4 mm). Las fotografías fueron evaluadas por un panel conformado por ortodoncistas, cirujanos dentistas y personas no expertas. La evaluación se realizó a través de una escala visual análoga. Resultados: La fotografía con la posición normal del incisivo central superior con respecto a la línea GALL fue mejor valorada por los ortodoncistas (67,658 ± 22,094) y por los no expertos (54,038 ± 20,524). Los cirujanos dentistas consideraron más agradable la posición protruida (60,804 ± 3,626). Se encontraron diferencias significativas entre los grupos de evaluadores y las fotografías (p < 0,05). Conclusiones: Los ortodoncistas mostraron una valoración de la estética más cercana a la norma para la posición anteroposterior de los incisivos. La posición anteroposterior de los incisivos juega un rol importante en la percepción de la estética de la sonrisa en norma lateral(AU)

ABSTRACT Introduction: Orthodontic treatment is mainly aimed at achieving stable occlusal relationships and enhancing the smile expression. The position of the upper central incisors plays a particularly important role in such an expression, and extracranial references have been suggested for its proper three-dimensional position. Awareness of the preferences of the various social actors involved may be useful to make appropriate decisions when planning the treatments. Objective: Evaluate the esthetic perception that orthodontists, dental surgeons and laypeople have of the smile with the upper central incisor in anteroposterior position with respect to the forehead and in lateral norm. Methods: A lateral norm photograph was used of a Peruvian woman with a normal profile and ideal anteroposterior position of the upper central incisor according to element II of Andrews' orofacial harmony. The photograph was digitally modified to obtain images with retruding (- 4 mm) and protruding (+ 4 mm) incisors. The photographs were evaluated by a panel composed of orthodontists, dental surgeons and laypeople. The evaluation was based on a visual analog scale. Results: The photograph with normal position of the upper central incisor with respect to the GALL line was ranked higher by orthodontists (67.658 ± 22.094) and laypeople (54.038 ± 20.524). To dental surgeons the protruded position was nicer (60.804 ± 3.626). Significant differences were found between the groups of evaluators and the photographs (p < 0.05). Conclusions: The esthetic appraisal of orthodontists was closer to the norm for anteroposterior position of incisors. The anteroposterior position of incisors plays an important role in the esthetic perception of the smile in the lateral norm(AU)

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Extramedullary plasmacytoma represents less than 5% of plasma cell malignancies, 85% corresponding to head and neck masses. Symptoms are related to compressive effects according to location, aesthetics issues and can be misleading associated with soft tissue disorders. In this case report, we discuss a 70-year-old woman who presented with a 3-month history of a growing painless forehead lump and confusion, for which she had an emergent simple head computed tomography scan. The images revealed a well-defined mass eroding the frontal bone with multiple lytic lesions that were also found along with long bones radiography. The mass biopsy showed a monomorphic plasmatic cell infiltrate, bone marrow studies confirmed the diagnosis of a light chain secreting multiple myeloma. Extramedullary plasmacytoma is a very unusual first presentation form of multiple myeloma and represents a clinical and radiological challenge. A systematic approach of lytic bone lesions along with the differential diagnosis of head masses are skills the clinician should develop to promptly recognize this condition considering further complications of delayed treatment. In this case, the histopathological confirmation allowed the patient to avoid neurosurgery and the early start of systemic chemotherapeutic treatment.

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Introdução: Paciente com diagnóstico de paquidermoperiostose, apresentando forte manifestação cutânea, impossibilitando a correção do defeito pelas técnicas usuais de lifting facial. O lifting frontal reverso foi a técnica idealizada para o caso. É uma técnica inovadora, não havendo publicação prévia na literatura. Relato de caso: Paciente italiano, sexo masculino, 56 anos, apresentando síndrome de manifestação cutânea, em especial na região frontal da face, com pele inelástica de aspecto coriáceo, que gerava desconforto estético, ensejando um estigma sindrômico. Métodos: A técnica elaborada para este caso envolve incisão, que se inicia na raiz da hélice (ponto A), contorna o supercílio em linha sinuosa distando meio centímetro da implantação dos pelos da sobrancelha, indo até a região da glabela, curvando para a raiz do nariz e indo se encontrar com dimensões idênticas do outro lado. Do ponto A, também ascende uma linha curva inclinando-se para o sentido medial, com uma distância de 2cm. A intenção é diminuir a distância entre a área a ser tracionada e a área de incisão, a fim de obter maior tração, possibilitando assim a correção do aspecto da face em foco. Resultados: A tração caudal do retalho por incisão supraciliar possibilitou a correção do defeito em região frontal sem que houvesse alteração da linha de implantação capilar ou ascensão excessiva das sobrancelhas. Conclusão: A técnica de lifting frontal reverso foi criada para um caso específico de síndrome de paquidermoperiostose. Quando bem indicada esta técnica pode ser utilizada atingindo bons resultados.

Introduction: Patient diagnosed with pachydermoperiostosis, presenting a strong cutaneous manifestation, making it impossible to correct the defect by the usual facial lifting techniques. The reverse frontal facelift was the idealized technique for this case. It is an innovative technique, there being no previous publication in the literature. Case report: Italian male patient, 56 years old, with cutaneous manifestation syndrome, especially in the frontal region of the face, with leathery inelastic skin, which generated aesthetic discomfort, predisposing for a syndromic stigma. Methods: The technique developed for this case involves an incision, which starts at the root of the helix (point A), bypasses the eyebrow in a sinuous line distant half a centimeter from the implantation of the eyebrow hair, going to the glabella, curving towards the nasal root and going to meet identical dimensions on the other side. From point A, a curved line also leans towards the medial direction, at a distance of 2 cm. The intention is to reduce the distance between the area to be pulled and the incision area, in order to obtain more traction, thus enabling the correction of the aspect of the face in focus. Results: Caudal traction of the flap by a supraciliary incision made it possible to correct the defect in the frontal region without altering the capillary implantation line or causing excessive eyebrow rise. Conclusion: The reverse frontal lifting technique was created for a specific case of pachydermoperiostosis syndrome. When correctly indicated, this technique can be used to achieve good results.

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A fasciite nodular é um tumor benigno, decorrente da proliferação reativa de células fibroblásticas ou miofibroblásticas de rápido crescimento e rica celularidade. Em adultos, o acometimento das extremidades é mais frequente; entretanto, outras regiões podem ser acometidas. Neste relato, é apresentada paciente feminina de 40 anos, com lesão nodular na fronte, com diagnóstico de fasciite nodular confirmado à histopatologia. O caso relatado procura destacar sua rara localização e alertar o dermatologista clínico para a sua inclusão entre os diagnósticos diferenciais das lesões tumorais na face.

Nodular fasciitis is a benign tumor resulting from the reactive proliferation of fibroblastic or myofibroblastic cells presenting rapid growth and rich cellularity. In adults, the extremities' involvement is more frequent; however, other regions can be affected. In this report, we present the case of a 40-year-old woman with a nodular lesion on the forehead. The histopathology confirmed the diagnosis of nodular fasciitis. The reported case highlights its rare location and alerts the clinical dermatologist in its inclusion among the differential diagnoses of tumor lesions on the face.

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Objective: Impulsiveness has been the subject of much research, but little is known about the possible relationship between craniofacial anatomy and impulsiveness. The present study was designed to investigate the relationship between one aspect of craniofacial structure (the angle of inclination of the forehead) and impulsiveness. Method: Photographs in profile were obtained from 131 volunteers who had been fined for driving at high speed and were undergoing a court-mandated driving license point-recovery course. They completed the Barratt Impulsiveness Scale (BIS-11), the Impulsive Behavior Scale (UPPS-P), and Zuckerman's Sensation Seeking Scale (V). The angle of the slant of the forehead was measured with a photographic support and a protractor. Results: High positive concordance was found between forehead inclination and 14 out of the 15 impulsiveness factors studied. Conclusions: The angle of inclination of the forehead was significantly associated with self-reported impulsiveness in this sample of traffic violators.

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Introducción: El ala nasal es un área de frecuente incidencia de tumores malignos. La exéresis de estos, deja graves secuelas con repercusión negativa en el paciente. Objetivo: Caracterizar la reconstrucción de defectos totales del ala nasal en pacientes oncológicos. Método: Se realizó un estudio descriptivo, observacional, longitudinal y prospectivo en el Instituto Nacional de Oncología y Radiobiología desde abril de 2014 hasta abril de 2017. La muestra quedó conformada por 32 pacientes que cumplieron los criterios de selección. Resultados: Los pacientes del sexo masculino representaron la mayoría en el estudio. El carcinoma basal fue el diagnóstico histológico más frecuente. La resección de tumores primarios que resultaron en defectos aislados del ala nasal fueron el principal motivo de reconstrucción. El mayor porcentaje de los casos se reconstruyó de forma inmediata. El colgajo frontal fue la técnica más empleada, el cual presentó los mejores resultados estéticos y funcionales. El injerto compuesto de piel presentó el mayor índice de complicaciones. Conclusiones: Con el colgajo frontal doblado sobre sí mismo sin injerto de cartílago, se lograron los mejores resultados estéticos y funcionales(AU)

Introduction: Ala nasi is an area of frequent incidence of malignant tumors, whose exeresis leaves serious sequels with negative impact on the patient. Objective: To characterize nasal ala reconstruction for total defects in cancer patients. Method: A descriptive, observational, longitudinal and prospective study was carried out at National Institute of Oncology and Radiobiology, from April 2014 to April 2017. The sample consisted of 32 patients who met the selection criteria. Results: The study majority was represented by male patients. Basal carcinoma was the most frequent histological diagnosis. Resection of primary tumors that resulted in isolated defects of the nasal ala were the main reason for reconstruction. The highest percentage of cases were reconstructed immediately. The forehead flap was the most used technique, and presented the best aesthetic and functional results. The composite skin graft presented the highest rate of complications. Conclusions: With the forehead flap folded on itself and without cartilage graft, the best aesthetic and functional results were achieved(AU)

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Introduction: The long forehead gives a less harmonious appearance, seems disproportionate and characterizes the aging face. Surgical procedures for frontal reduction with precapillary incision present insightful information and provide harmonious and pleasant restoration of the frontal region. This study evaluated results obtained in patients who underwent frontal reduction using precapillary incision at Daher Hospital plastic surgery service within the last ten years. Methods: This was a retrospective longitudinal study. The surgical technique entailed a careful dissection of the bilateral supraorbital ridge. The scalp was dissected in the parietoccipital region in order to easily move forward the flap. The vigorous hemostasis and resection of excessive flap were performed. In the end, synthesis of plans were performed. Results: The age of patients ranged from 48 to 76 years, the mean age was 58 years. Mean surgical time was 3 hours and 38 minutes. No complications were seen such as hematoma, flap necrosis, supratrochlear nerve injury, alopecia, infections, deep vein thrombosis, pulmonary embolism and/or dehiscence. Four patients (7%) had seroma that was drained. The symmetric of eyebrows and scars positioning was considered satisfactory in both assessment by patients and the technical evaluator. Conclusion: The aesthetic results in patients who underwent frontal reduction by precapillary incision were satisfactory. The choice of the ideal patient was crucial for success of the surgery.

Introdução: A testa longa confere uma aparência menos harmônica, desproporcional e caracteriza o envelhecimento. Procedimentos cirúrgicos para redução frontal com incisão pré-capilar apresentam indicações criteriosas e proporcionam a restauração harmônica da região frontal. O estudo avalia os resultados obtidos em pacientes submetidos à redução frontal por incisão pré-capilar no serviço de cirurgia plástica do Hospital Daher nos últimos dez anos. Métodos: Trata-se de um estudo observacional longitudinal retrospectivo. A técnica cirúrgica consiste em uma dissecção cuidadosa até o rebordo supraorbital bilateral. O couro cabeludo é dissecado até a região parietoccipital de forma a avançar com facilidade o retalho. Procede-se à hemostasia vigorosa e ressecção do retalho excedente. Por fim, realiza-se a síntese por planos. Resultados: A faixa etária das pacientes variou de 48 a 76 anos, com média de 58 anos. O tempo médio operatório foi de 3 horas e 38 minutos. Não foram observadas complicações como hematoma, necrose do retalho, lesão do nervo supratroclear, alopécia, infecções, trombose venosa profunda, embolia pulmonar e/ou deiscências. Quatro pacientes (7%) apresentaram seroma, os quais foram todos drenados. A simetrização das sobrancelhas e a posição das cicatrizes foram consideradas satisfatórias tanto pela avaliação feita pelos pacientes quanto pela avaliação técnica. Conclusão: Os resultados estéticos obtidos em pacientes submetidos à redução frontal pela incisão pré-capilar foram satisfatórios. A escolha do paciente ideal foi fundamental para o bom sucesso operatório.

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Nos últimos anos houve grande avanço nas técnicas não invasivas de rejuvenescimento facial. O maior entendimento das alterações anatômicas envolvidas no processo do envelhecimento foi acompanhado por rápida evolução na forma de abordar essas alterações e pela expansão de substâncias e tecnologias usadas nessa abordagem. Com relação ao arsenal de substâncias usadas para rejuvenescimento, o terço superior da face, era antes território quase exclusivo dos neuromoduladores. Atualmente, os preenchedores vêm ocupando lugar de destaque, especialmente aqueles à base de acido hialurônico (AH), porque são seguros e produzem resultados imediatos e duradouros, porém reversíveis. O objetivo deste primeiro artigo é oferecer breve revisão da literatura e atualização sobre o uso de preenchedores de AH no rejuvenescimento do terço superior da face, enfocando as regiões da fronte e da glabela.

In recent years there has been a breakthrough in non-invasive techniques of facial rejuvenation. The greater understanding of the anatomical changes involved in the aging process was accompanied by rapid evolution in how to address these changes and the expansion of substances and technologies used in this approach. Of the arsenal of substances used for rejuvenation, the upper third of the face was before an almost exclusive territory of neuromodulators. Currently, fillers have stood out, especially those based onhyaluronic acid (HA), because they are safe and produce immediate and lasting ­ but reversible ­ results. The objective of this first article is to provide a brief literature review and update on the use of HA fillers in the rejuvenation of the upper third of the face, focusing on the forehead and glabella areas.

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Paracoccidioidomycosis is an infectious disease whose etiological agent belongs to the Paracoccidioides genus. Although it affects primarily the lungs, it can spread to other tissues, including the skin and mucous membranes. Despite the clinical treatment for this disease, scarring can produce sequelae, manifesting as anatomical and functional deformities of the face. We present a case of extensive, nasal unaesthetic and functional sequelae resulting from paracoccidioidomycosis, reconstructed using the paramedian forehead flap in three stages, through the regional unit principles.

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Introducción: La reconstrucción nasal puede requerir el uso de colgajos provenientes de la frente, especialmente cuando otras técnicas reparadoras más sencillas no pueden ser realizadas. El presente trabajo muestra la utilidad de esta técnica. MATERIAL Y MÉTODO: estudio observacional, retrospectivo, transversal, de una serie de casos consecutivos, que incluye a pacientes adultos en quienes se realizó una reconstrucción nasal con colgajo frontal paramediano en un período de dos años. RESULTADOS: Ocho pacientes fueron tratados mediante esta técnica con rango etario entre 53 y 76 años. Se realizaron reconstrucciones nasales en dos o tres tiempos con éxito. No se constataron complicaciones postoperatorias. CONCLUSIÓN: El colgajo frontal paramediano ocupa un lugar en el arsenal terapéutico destinado a la reconstrucción nasal.

Introduction: The nasal reconstruction may require the use of flaps from the forehead, especially when other simpler repair techniques can’t be performed. This study shows the usefulness of this technique. MATERIALS AND METHODS: An observational study, retrospective, transversal, of consecutive case series, which includes adult patients who underwent nasal reconstruction with paramedian forehead flap over a period of two years. RESULTS: Eight patients were treated by this technique with age range between 53 and 76 years. The nasal reconstructions were performed in two or three times with success. No postoperative complications were noted. CONCLUSION: The paramedian forehead flap has a place in the treatment armamentarium for nasal reconstruction.

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INTRODUÇÃO: Seiscentos anos antes de Cristo, foi descrito o retalho médio-frontal pelo indiano Sushruta Samhita. Até hoje, esse retalho, chamado ''retalho indiano", é usado na reconstrução do nariz. O objetivo deste trabalho foi analisar os resultados da 38ª Enfermaria da Santa Casa da Misericórdia do Rio de Janeiro, Serviço do Professor Ivo Pitanguy, na reconstrução nasal com emprego de retalho médio-frontal. MÉTODO: Foi realizado estudo retrospectivo com 10 casos operados no serviço referido para reconstrução nasal com retalho indiano, no período de 21 anos (1991 a 2012). RESULTADOS: O número de subunidades nasais atingidas variou de 4 a 9, com média de 6,5 subunidades. Em 70% dos pacientes foi realizada expansão prévia do retalho médio-frontal e em 90% foram utilizados enxertos cartilaginosos e/ou ósseos. Cinco pacientes apresentaram distorções pós-operatórias, que foram corrigidas por outras cirurgias. Nenhum caso de infecção pós-operatória, de necrose do retalho ou de extrusão de enxertos foi registrado. CONCLUSÕES: Este trabalho permitiu demonstrar que o retalho médio-frontal tem ainda importante papel na reconstrução nasal de grandes defeitos, com resultados satisfatórios, atribuídos a sua segurança vascular, à quantidade de pele que se obtém, e à semelhança de cor, textura e espessura cutâneas.

BACKGROUND: Six hundred years before Christ, the mid-forehead flap was described by the Indian Sushruta Samhita. Until today, this flap called ''Indian flap", has a major role in the reconstruction of the nose. The aim of this work was to analyze the results of the 38th Infirmary of the Santa Casa da Misericórdia of Rio de Janeiro, Professor Ivo Pitanguy's Service, in nasal reconstruction with the mid-forehead flap. METHODS: We did a retrospective study of 10 cases operated in the service for nasal reconstruction with Indian flap, during a 21 year period (1991-2012). RESULTS: The number of nasal sub-units affected varied from 4 to 9, with an average of 6.5 subunits. In 70% of the patients, was performed a previous expansion of the mid-forehead flap and in 90% were used cartilage grafts and/or bones. Five patients had postoperative distortions, that were corrected with other surgeries. No cases of infection, necrosis of the flap or graft extrusion were recorded. CONCLUSIONS: This study allowed to demonstrate that the mid-forehead flap still have an important role in nasal reconstruction of major defects, showing satisfactory results due to its vascular safety, the amount of skin which is obtained, likeness of color, texture and skin thickness.

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INTRODUÇÃO: A testa longa pode dar uma aparência menos atraente, desproporcional e caracterizar o envelhecimento. O objetivo deste trabalho é demonstrar a experiência dos autores na redução da região frontal com incisão pré-capilar e reforçar as indicações desse procedimento. MÉTODO: Foram estudados, retrospectivamente, pacientes submetidos a redução da região frontal por incisão pré-capilar, no período de 2005 a 2011. As indicações para incisão anterior na linha do cabelo foram ptose da sobrancelha, em pacientes que possuíam cabelos frontais finos e escassos, testa longa congênita ou enrugamento amplo de testa. RESULTADOS: A incisão pré-capilar foi realizada em 31 pacientes, com acompanhamento médio de 1,5 ano. Não houve problemas relacionados à vascularização do retalho. Todos os pacientes relataram parestesia temporária, com recuperação em até 1 ano. Três pacientes apresentaram seromas no pós-operatório, tratados com punção. Todos os pacientes relataram que os benefícios da redução da linha do cabelo ultrapassaram as desvantagens de uma cicatriz possivelmente mais visível. CONCLUSÕES: O procedimento de ritidectomia frontal com incisão pré-capilar é indicado para pacientes com cabelos frontais finos e escassos, com enrugamento amplo da testa ou com testa longa congênita/senil e que desejem reduzi-la.

BACKGROUND: A long forehead can give a less attractive and disproportionate appearance. It may also indicate aging. The objective of this study is to show the experience of the authors in forehead reduction using precapillary incision and to support the indications for this procedure. METHODS: Patients who underwent precapillary incision for forehead reduction between 2005 and 2011 were retrospectively analyzed. The indications for an anterior hairline incision were eyebrow ptosis in patients with thin and sparse frontal hair, congenital long forehead, or extensive forehead wrinkles. RESULTS: Precapillary incision was performed in 31 patients, who were followed up for an average of 1.5 years. No problems related to flap vascularization were detected. All patients reported temporary paresthesia, from which they recovered within 1 year. Three patients presented seromas during the postoperative period and were treated using puncturing. All patients reported that the benefits of altering the hairline were greater than the disadvantages of a possibly more visible scar. CONCLUSIONS: Frontal rhytidectomy using precapillary incision is recommended in patients who wish to correct thin and sparse frontal hair, extensive forehead wrinkles, or congenital/senile long forehead.

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Extensive defects of the scalp and forehead associated with calvarial bone resections demand complex reconstructions. Free flaps offer vascularized tissue of excellent quality and quantity. We report six patients with extensive scalp and forehead defects associated with calvarial bone resections reconstructed with free flaps. Five patients also required a cranioplasty. The flaps used were two anterolateral thigh flaps, one vastus lateralis flap, one myocutaneous latissimus dorsi flap, one latissimus dorsi flap, and one radial forearm flap. All flaps survived with no partial necrosis. There were no donor site complications. One patient presented an exposure of the alloplastic material used for cranioplasty. We strongly recommend the use of free flaps for this kind of reconstruction.