Large Forehead Research Articles

Forehead Reduction: A Systematic Review and Meta-Analysis of Outcomes.

Importance: Forehead reduction, or hairline lowering surgery, is becoming more popular as a cosmetic procedure for patients with disproportionately large foreheads. A large forehead can make a patient appear older, be masculinizing, and less attractive. Objective: To quantify reported outcomes in patients undergoing forehead reduction. Methods: We performed a systematic review and meta-analysis of adults undergoing forehead reduction. A review protocol was published in PROSPERO (CRD42020183366). A research librarian created search strategies in multiple databases. Abstracts and full texts were reviewed in duplicate. The Newcastle-Ottawa scale and Cochrane Collaboration Risk of Bias tool were used. Random effects meta-analyses were performed. The primary outcome was amount of reduction. Other extracted data included study type, location, sample size, scalp fixation method, incision, complications, follow-up time, percentage female, and age. Results: Our search strategy found 376 unique citations, and 8 studies were included. All eight were retrospective cohort studies, comprising 882 patients (range 5-525). Study quality was high, and risk of bias ranged from unclear to high. Four studies were included for meta-analysis, totaling 801 patients. Mean amount of reduction was 1.6 cm (95% confidence interval: 1.4-1.8). Complications included temporary and permanent alopecia, unacceptable scarring, persistent paresthesia, and hematoma. The pooled complication rate was 1% or less. Conclusion: Forehead reduction is associated with a low complication rate (<1%), and a mean lowering of 1.6 cm is reported. Future studies should report mean and standard deviation of reduction, and should follow patients for at least 12 months.

Expanded Forehead Stepped Flaps for Delayed Three-Stage Repair of Midface Skin Lesions

The forehead flap is the best flap for nasal defect repair and nasal reconstruction. It is also an ideal option for repairing skin lesions in the midface (including the nasal area, inner area of the cheek, and upper lip of the perioral area). However, the traditional frontal myocutaneous flap is relatively bulky for repairing pure skin lesions. In addition, the original forehead flap is generally not sufficient to cover a large wound area. If a large forehead flap is removed, the donor site cannot be sutured in one stage. In this study, an expanded forehead stepped flap was used to overcome the shortcomings of the traditional frontal myocutaneous flap. In stage one surgery, a rectangular expander (80–100 mL) was implanted on the side of the forehead. The expansion pot was built-in, and the excess expansion amount was 160–200 mL. After 4 weeks of rest, stage two operation was performed to remove the skin lesions in the midface. The pulsation point of the supratrochlear artery on one side was used as the pedicle, and the flap was designed diagonally to the upper region of the opposite side. The flap was designed according to the size and shape of the wound. The distal portion of the flap was separated in the superficial layer of the frontalis muscle, approximately 1.7 cm above the superior orbital edge, and cut into the submuscle. The flap pedicle was cut from the superficial layer of the periosteum to form a stepped flap. Then, the flap was rotated downward to repair the wound in the midface. Five weeks later, stage three of the operation which involved flap pedicle division, was performed. Expanded forehead stepped flaps were used in 12 cases with 6–36 months of follow-up. In all cases, the blood supply to the flaps was good, and their color, texture, and thickness matched well with those of the surrounding skin. All patients were satisfied with the outcome of the repair. Expanded forehead stepped flaps present an ideal option for repairing wounds after large skin lesion resections in the midface since they have multiple edges from a reliable blood supply, easiness to transfer, and well-matched color, texture, and thickness to those of the surrounding skin of the face to no need for many auxiliary incisions.

An Anchor Flap as a Novel Method for Large Forehead Defects Reconstruction

Background: Extensive forehead defects remain a challenge in reconstructive surgery. The choice of reconstruction method is a significant clinical problem, not only for cosmetic reasons but also because of possible complications. The anchor flap provides a promising solution for large (7 cm diameter) skin defects reconstruction in the temple area. In this article, we describe a novel method for extensive forehead defects reconstruction. Methods: We present a method for reconstruction of forehead skin defect with an Anchor flap after tumor resection. A 78-year-old female patient who received oncologic reconstruction in the present study were included. Results: There were no early or late complications during the two years of the follow-up period. The flap survived without partial or complete necrosis, infection, or other complications. The aesthetic outcome was very satisfying and well documented. Conclusion: The Anchor flap enables to achieve tension-free frontotemporal defect closure after tumor resection, with satisfactory clinical and aesthetic results. This method is a reliable reconstructive surgical technique for the reconstruction of extensive forehead defects.

Use of Pericranial Flaps with Dermal Substitute for Scalp Reconstruction: A Case Series.

Background:Skin cancer incidence has been rapidly increasing over the past 2 decades, and the resulting defects from excision have significant aesthetic and functional implications. In particular, wound coverage for large scalp and forehead defects with calvarial exposure can lead to hairline distortion, contour irregularities, and alopecia. We describe a 2-stage technique for scalp reconstruction, which preserves the normal hairline, covers exposed bone with vascularized tissue, and restores an aesthetic soft-tissue contour.Methods:This is a retrospective case series of 13 adults with ages ranging from 50 to 89 years. All patients underwent Mohs surgery on the forehead or scalp between July 2014 and April 2017. Patients underwent a 2-staged reconstruction with an initial pericranial flap and dermal substitute placement followed by the placement of a split-thickness skin graft within 4–6 weeks.Results:Over a 3-year period, 13 patients had successful reconstruction of the scalp defect without alteration of the hairline or contour irregularity. Two patients had minor complications after the first-stage procedure with successful aesthetic reconstruction.Conclusions:Full-thickness defects of the scalp and forehead with bone exposure provide a reconstructive challenge for plastic surgeons. Reconstructive algorithms continue to evolve and should be tailored to best suit patients’ needs and medial comorbidities. Two-staged reconstruction with local pericranial flap provides a safe and efficacious reconstruction that minimizes hairline distortion, contour irregularity, and donor site morbidity.

Triple-Plane Dissection of Combined Forehead and Scalp Flaps for Large Posttraumatic Forehead Defects

Abstract Introduction Reconstruction of large (&gt;20 cm2) posttraumatic forehead defects, with esthetically pleasing results and without distorting the surrounding anatomical landmarks like eyebrow and hairline, is a significant surgical challenge. This study was aimed to determine the effectiveness of a triple-plane dissection technique of significantly-sized flaps, combining forehead, and scalp to cover large forehead defects. Materials and Methods A retrospective review from January 2009 to December 2019 revealed that 12 patients with large defects over the forehead were operated on. Significantly-sized rotation and advancement flaps, combining both the forehead and scalp tissues, were performed. Triple-plane dissection and careful galeal scoring recruited more tissues and increased the reach of these flaps while maintaining adequate flap vascularity. Results Large forehead posttraumatic defects in all 12 patients were covered in a single surgery with this combined flap. Eight patients were men and four were women (mean age, 58 years). Size of the defects ranged from 21 to 40 cm2 (mean, 27 cm2). Complications included deep marginal necrosis in one patient (8%), superficial necrosis in one patient (8%), and mild venous stasis in four patients (33%). Superficial necrosis and venous stasis resolved by itself. Good color and contour match, minimal alopecia, maintained positions of eyebrow, and hairline positions were found in most patients. Six months postoperatively, patient satisfaction measured on a visual analogue scale ranged between 3 and 9 out of 10 (mean, 7). Conclusion Primary forehead reconstruction with significant-sized flaps combining forehead and scalp tissues, with triple-plane dissection and galeal scoring, appears to be an effective option for covering large forehead defects.

Forehead location and large segmental pattern of facial port-wine stains predict risk of Sturge-Weber syndrome

Children with forehead port-wine stains (PWSs) are at risk of Sturge-Weber syndrome (SWS). However, most will not develop neurologic manifestations. To identify children at greatest risk of SWS. In this retrospective cohort study of children with a forehead PWS, PWSs were classified as "large segmental" (half or more of a contiguous area of the hemiforehead or median pattern) or "trace/small segmental" (less than half of the hemiforehead). The outcome measure was a diagnosis of SWS. Ninety-six children had a forehead PWS. Fifty-one had a large segmental PWS, and 45 had a trace/small segmental PWS. All 21 children with SWS had large segmental forehead PWSs. Large segmental forehead PWSs had a higher specificity (0.71 vs 0.27, P<.0001) and a higher positive predictive value (0.41 vs 0.22, P<.0001) for SWS than any forehead involvement by a PWS. Retrospective study at a referral center. Children with large segmental forehead PWSs are at highest risk of SWS.

Dawn of the Soviet Jet Age: Aeroflot Passengers and Aviation Culture under Nikita Khrushchev

Dawn of the Soviet Jet AgeAeroflot Passengers and Aviation Culture under Nikita Khrushchev Steven E. Harris (bio) In the short story “Aeroflot,” an old woman sees an ad for the airline: “Fast, inexpensive, comfortable, saving time. Fly north, fly south, fly on business, fly for pleasure, fly to all corners of the world.” The narrator describes the ad’s image of a jet-plane interior as a domestic space promoting internationalism. “A young woman gives her baby tea to drink and looks through the small window onto the sugar-like clouds. A black man with a large forehead holds a newspaper in his large hands, while passengers play chess as if they were at a table at home.” One day, the old woman is gripped by the ad’s message. She yearns to be young and healthy again, to visit her children and grandchildren. In a dream that night, she projects herself into the ad “in the wonderful machine [where] she gave her child tea to drink, the black man with the large forehead smiled at her with his big teeth and big lips. You could just touch the clouds outside the airplane’s window. What happiness! She’s flying!” Suddenly, a doctor wakes her and says she’s had a heart attack. “Did something happen to you?” he asks. “No,” she mumbles, but the narrator concludes, “How could he have known that the old woman had been flying?”1 With this story, the Soviet writer Ida Shuĺkina updated the Icarus myth for the Jet Age, which passengers began to enjoy in 1956 on the Tupolev-104. In the early 20th century, visionary inventors and reckless pilots had played the role of the Greek hero for audiences who largely experienced flight [End Page 591] vicariously through their heroic feats. The old woman who replaces them in Shuĺkina’s story was a passenger, one of millions who flew Aeroflot annually and experienced the mobility and anxieties of jet travel. This article explores how representations of Aeroflot’s passengers became a critical source of information about the Soviet Jet Age and moved from the margins of aviation culture under Iosif Stalin to its center under Nikita Khrushchev. With the emergence of the passenger as the chief subject of aviation culture, the public not only received practical information on flying but learned what it meant to be a Soviet citizen in an age marked by rapid technological changes and improved mass consumption, the ideological stakes of which were accentuated by the Cold War. Echoing the superpower conflict, Aeroflot’s rivalry with Pan American World Airways shaped the socialist values of jet travel but also revealed the tension between expanded aerial mobility at home and strict limitations on foreign travel. Although Shuĺkina’s story intimated travel “to all corners of the world,” aviation culture tempered such aspirations by celebrating air travel as a domestic affair and reframing international routes as signs of Soviet prestige and prowess on the world stage. As proposed in this article, aviation culture provides a good entry for understanding how the Jet Age shaped the Khrushchev era. In his pioneering work on aviation culture in the first half of the 20th century, Robert Wohl opened this field for American and West European history by using a variety of sources from poetry and advertisements to film and memoirs to reveal the cultural and political meanings airplanes generated.2 In Russian historiography, scholars have similarly examined aviation culture, focusing primarily on the Stalin era but also late imperial Russia and the 1920s. Examining all three periods, Scott Palmer has shown how aviation culture bolstered the state’s legitimacy and helped define a Soviet path to modernity despite dependence on Western technology.3 Aviation culture after Stalin, however, remains [End Page 592] largely unexplored. Scholars have provided specialized studies on airplane design, military aviation, air routes, and administration but not the social and cultural roles of aviation in the Khrushchev era.4 Only one scholar, a US historian, has studied Aeroflot flight attendants and how their representations intersected with those from Pan Am.5 Although the closely related Soviet space program has attracted scholarly attention, the role of passengers...

Anesthesia management in a patient with Zellweger syndrome

Objective: Zellweger syndrome (ZS) is an autosomal recessive disorder in the spectrum of peroxisome biogenesis disorders including punctate and is defined as cerebrohepatorenal syndrome due to multiple congenital anomalies including brain, liver and kidneys. We wanted to draw attention to this issue by sharing our anesthetic experiences in a child with Zellweger syndrome. Case: Appendectomy was planned by pediatric surgery in a 4 year old and 16 kg male patient who was diagnosed as Zellweger syndrome. Physical examination revealed large forehead, large tongue, small chinhypotony, mental motor retardation, and hepatosplenomegaly. Following the introduction of routine monitors, anesthesia were induced intravenously and maintained with sevoflurane in an 50% oxygen- 50% air mixture. The patient was intubated and ventilated with a safe pressure control mode. The patient was hemodynamically stable during surgery. After spontaneous breathing of the patient, extubation was applied smoothly. Conclusion: Zellweger syndrome includes alarming features for the anesthesiologist. Before any procedure, the pulmonary condition should be carefully evaluated. Hepatic dysfunction may lead to a change in the metabolism of drugs based on hypoalbuminemia, coagulopathy and liver pathways. Since liver dysfunction may lead to coagulopathy, caution should be exercised when applying regional anesthesia techniques.

Large Forehead Mass Resulting From Chronic Head Banging.

Head banging is a commonly observed movement disorder which is typically self-limited. Complications secondary to this behavior are rare. In this report, the authors present the case of a 15-year-old patient who was treated for a forehead mass which developed secondary to chronic head banging. Surgical excision was performed for treatment of the lesion. Results from surgical pathology were notable for fibrosis consistent with history of chronic head banging. Preoperative magnetic resonance imaging and physical examination were also consistent with this diagnosis. This is a rare clinical entity that should be considered in patients presenting with a forehead mass and a history of head banging.

Repair of a Large Forehead Defect

Repair of a Large Forehead Defect

Large Forehead Nodule with Multiple Facial and Oral Papules

Large Forehead Nodule with Multiple Facial and Oral Papules

Prenatal diagnosis of partial monosomy 5p (5p15.1→pter) and partial trisomy 7p (7p15.2→pter) associated with cystic hygroma, abnormal skull development, and ventriculomegaly

ObjectivePrenatal diagnosis of concomitant chromosome 5p deletion syndrome and chromosome 7p duplication syndrome in a fetus with abnormal prenatal ultrasound is presented. Case ReportA 34-year-old woman was referred for amniocentesis at 22 weeks of gestation because of an irregular-shaped skull, bilateral ventriculomegaly, and nuchal cystic hygroma. Amniocentesis revealed a derivative chromosome 5 with a distal 5p deletion and an addendum of an extra unknown chromosomal segment at the breakpoint of 5p. Cytogenetic analysis of parental bloods revealed a karyotype of 46, XX, t(5;7)(p15.1;p15.2) in the mother and a karyotype of 46,XY in the father. The karyotype of the fetus was 46, XX, der(5) t(5;7)(p15.1;p15.2)mat consistent with partial monosomy 5p (5p15.1→pter) and partial trisomy 7p (7p15.2→pter). A malformed fetus was subsequently delivered with an irregular-shaped skull, a large anterior fontanelle, brachycephaly, hypertelorism, a high and prominent forehead, a large nuchal cystic hygroma, large low-set ears, a short and flattened nose, and micrognathia. Array comparative genomic hybridization analysis of the placenta revealed the result of arr 5p15.33p15.1 (22,179-18,133,327)×1.0, 7p22.3p15.2 (54,215-25,551,540)×3.0, indicating an 18.11-Mb deletion of 5p (5p15.33-p15.1) and a 22.5-Mb duplication of 7p (7p22.3-p15.2). Cord blood sampling revealed a karyotype of 46, XX, der(5)t(5;7) (p15.1;p15.2)mat. ConclusionFetuses with 5p deletion syndrome and 7p duplication syndrome may present ventriculomegaly, abnormal skull development, and cystic hygroma on prenatal ultrasound.

Morphological and sexual traits in Atlas and Iberian Pied Flycatchers Ficedula hypoleuca speculigera and F. h. iberiae: a comparison

ABSTRACTCapsule: There are significant biometric differences between Pied Flycatchers from Iberian and north African populations which are consistent with proposals to classify the two forms into separate species.Aims: To determine the similarities and differences in the main biometrical and plumage sex traits between populations of the Iberian Pied Flycatcher Ficedula hypoleuca iberiae and the Atlas Flycatcher Ficedula hypoleuca speculigera.Methods: Biometric and plumage traits of 193 breeding individuals of Iberian Pied Flycatchers and 43 Atlas Flycatchers were measured in 2014 with standardized protocols.Results: Both sexes of Atlas Flycatchers were larger than Iberian Pied Flycatchers in skeletal (tarsus) and wing size and also differed in bill morphology, which was wider but shallower in speculigera than iberiae, with females (but not males) having shorter bills than iberiae females. Males differed in mantle colour and forehead patch size, with speculigera males being darker and displaying larger forehead patches than iberiae males. As in populations of iberiae, some speculigera females also expressed a white forehead patch.Conclusion: We demonstrate significant phenotypic differences between Iberian Pied Flycatchers and Atlas Flycatchers with respect to size and traits of ecological and evolutionary relevance, supporting the recently proposed scenarios on their independent evolution.

Two-dimensional morphometric analysis of young Asian females to determine attractiveness.

Introduction:Attractive people do not seem to consistently possess such ideal characteristics or share common features. There is no general consensus about the linear and angular characteristics that discriminate between attractive and normal persons.Aim:This study determines how young Asian women considered to be attractive differ in their twodimensional facial characteristics from normal women of the same age and race.Materials and Methods:Frontal and lateral photographs of 70 young Asian females were taken under standardized setting and were given to 15 judges who did not know the subjects in the study, to rate the attractiveness of each photograph. All 70 photographs were arranged in descending order of their total score by all the judges and were classified into three groups. Three angular, 8 linear measurements, and 3 ratios were compared between these groups.Results:This study showed that most attractive group had least convex face, larger forehead, and wider faces. Conversely, the middle facial height was larger in the least attractive group. The ratio of middle third to total face of the most attractive group is higher than the average attractive ones. The ratio of lower third to total face of the most attractive group is lower than the average attractive ones.

Acanthosis nigricans chez l’enfant et syndrome de Crouzon

Crouzon syndrome with acanthosis nigricans is a rare form of Crouzon syndrome in which craniosynostosis and facial dysmorphism are associated with acanthosis nigricans. Cutaneous examination of a 9-year-old child presenting bicoronal craniosynostosis revealed acanthosis nigricans of the cervical, axillar, inguinal and popliteal regions which appeared at the age of two. He had a dysmorphic face including a large forehead, hypertelorism, mid-face hypoplasia, prognathism and low-set ears. These clinical anomalies suggested a case of Crouzon syndrome with acanthosis nigricans, which was later confirmed by the finding of a mutation in the FGFR3 gene. Acanthosis nigricans in children is often a cutaneous marker of insulin resistance. However, it may also form part of diverse diseases, notably those of genetic origin. The association of craniosynostosis and acanthosis nigricans allows incrimination of the FGFR3 gene from the outset and diagnosis of Crouzon syndrome with acanthosis nigricans. In the present case, dermatological examination allowed an aetiology of craniosynostosis to be determined.

Fumarase Deficiency Associated With Noninflammatory Biliary Atresia

Fumarase Deficiency Associated With Noninflammatory Biliary Atresia

A somatotropin-producing pituitary adenoma with an isolated adrenocorticotropin-producing pituitary adenoma in a female patient with acromegaly, subclinical Cushing’s disease and a left adrenal tumor

A 67-year-old female with hypertension and impaired glucose tolerance was admitted to our hospital because of a typical acromegalic appearance, including large, thickened bulky hands and feet, and a large prominent forehead and tongue. She did not have a Cushingoid appearance, such as a moon-face, buffalo hump, purple striae or central obesity. The laboratory data revealed a serum GH level of 4.6 ng/mL and serum insulin-like growth factor-1 level of 811 ng/mL. The oral glucose tolerance test showed no suppression of the GH values. An endocrine examination showed a lack of circadian rhythmicity of ACTH and cortisol. Cortisol was not suppressed by a low dose of dexamethasone during the suppression test, but was suppressed by a high dose of dexamethasone. A radiological study revealed two isolated adenomas in the pituitary and a left adrenal tumor. These findings strongly suggested a diagnosis of acromegaly with subclinical Cushing's disease and a left adrenal incidentaloma. Transsphenoidal surgery was performed. Hematoxylin and eosin staining showed that the left and right pituitary adenomas were composed of basophilic and acidophilic cells, respectively. Immunohistochemical staining showed the left adenoma to be positive for ACTH and negative for GH. In contrast, the right adenoma was GH-positive and ACTH-negative. This is a rare case of independent double pituitary adenomas with distinct hormonal features. We also provide a review of the previously reported cases of double pituitary adenomas and discuss the etiology of these tumors.

Females Paired with More Attractive Males Show Reduced Oxidative Damage: Possible Direct Benefits of Mate Choice in Pied Flycatchers

AbstractDirect benefits of female mate choice may concern female fertility and fecundity but also physiological status. In birds with biparental care, males may contribute to improve the condition and health of their pair‐mates through help in constructing nests, incubation or incubation feeding and nestling provisioning. They may also reduce harassment of females by non‐pair males. A consequence of these male activities could be expressed in terms of oxidative damage, which may depend on metabolic effort and social stress. Here, we have related male contribution to parental and territorial duties to female oxidative status in the pied flycatcher Ficedula hypoleuca, a species where preferred males present darker dorsal plumage and, in Iberian populations, a large white forehead patch. Darker males were paired with females with high incubation attendance and reduced nestling provisioning rates, which may lead to reduced female exertion. These males owned nest boxes at which there were fewer visits by non‐pair males. Although females paired with dark mates worked less hard, they were able to raise more fledglings. Female oxidative damage measured as malondialdehyde (MDA) level in plasma declined with increasing incubation attendance and male incubation feeding. Moreover, levels of MDA in females declined with both darkness of male dorsal plumage and male forehead patch size when controlling for female forehead patch size and male age. The effect of male plumage darkness was especially strong. Females paired with middle‐aged males (2–3 yr) showed reduced levels of MDA compared with those paired with 1‐yr‐old and more than 3‐yr‐old males. Male age could not explain the effects of male attractiveness. Females paired with attractive males were more successful in reproduction while suffering reduced oxidative damage, possibly mediated by help during incubation and nestling rearing from their pair‐mates. Although correlative, the evidence suggests direct benefits of females paired with more attractive males.

Forehead Patch Size Predicts the Outcome of Male–Male Competition in the Pied Flycatcher

AbstractMales of many animal species express ornaments that affect their reproduction opportunities through male–male competition or female mate choice. Such ornaments can, for example, inform conspecifics about the fighting ability, condition or territory ownership of the bearer. Pied flycatcher (Ficedula hypoleuca) males have a conspicuous white forehead patch that varies greatly in size. We examined whether the white forehead patch is an intrasexually selected trait in a Finnish population. We artificially manipulated forehead patch size to represent two naturally occurring extremes and competed males against each other in the presence of a female. Males with a large forehead patch were more aggressive than males with a small patch, whereas the original patch size of the male had no influence on aggression. Neither manipulated nor original patch size influenced resource dominance (over female or nest box). These results indicate that forehead patch signals fighting ability of the bearer in the pied flycatcher. The next step is to find out what kind of costs may maintain the honesty of this signal.

Closure of Scalp and Forehead Defects Using External Tissue Expander

To describe the novel use of an external tissue expander in the reconstruction of scalp and forehead defects. A prospective review was performed on 7 patients who underwent extirpation of head and neck malignant neoplasms resulting in scalp and forehead defects. Reconstruction was performed using an external tissue expander device. Patient clinical factors, defect size, and photographs were collected. Seven patients had large scalp and forehead defects ranging in greatest dimension from 5.0 ×4.0 to 8.0 ×7.0 cm. The external tissue expander was in place for 6 to 14 days, reducing the defect sizes by 50% to 99%. At the time of device removal, primary closure was achieved in 5 patients. One patient required bilateral advancement rotation flaps, and 1 patient healed by second intention. One patient with a history of scalp irradiation and diabetes had partial skin loss after device removal and required reconstruction with a latissimus dorsi myocutaneous free flap. There were no other postoperative complications, wound breakdown, or device failures. External tissue expansion is a safe and effective technique for closing large scalp and forehead defects that would otherwise require skin grafting or free flap reconstruction.