Reconstruction of Large Supra-Eyebrow and Forehead Defects Using the Hatchet Flap Principle and Sparing Sensory Nerve Branches

Background: To reconstruct a forehead defect, a plastic surgeon must be knowledgeable about the neural, vascular, and muscular anatomy. The position of fixed structures such as eyebrows and hairline should be respected. For the past 5 years, we have used double hatchet flaps for reconstruction of relatively large supra-eyebrow and forehead defects. Because this flap does not appear to be among the techniques used by young plastic surgeons, we thought that it would be valuable to report our experience. Methods: Supra-eyebrow and forehead defects ranging from 2.5 x 2.5 cm to 3.5 x 3.5 cm were reconstructed using double hatchet flaps in 10 patients. Pearls and pitfalls of the technique are discussed along with the presentation of 3 cases. Results: The reconstructions were uneventful and the flaps were highly viable in all patients. There was no significant distortion in the eyebrow or hairline due to reconstruction in any of the patients. All the flaps were sensate. A mild anesthesia in the distribution of supraorbital/trochlear nerve proximal to the flaps was noted only in 3 patients. This was associated with inevitable nerve damage during excision of malignant skin lesions and/or flap dissection. No recurrence was noted during the follow-up period which ranged from 6 to 36 months (mean, 13.5 months). Overall patient satisfaction score based on scar appearance and perceived degree of forehead anesthesia was 3 (neither satisfied nor dissatisfied) in 1 patient, was 4 (somewhat satisfied) in 4 patients, and was 5 (very satisfied) in 5 patients. Conclusion: Hatchet flaps have similar color and texture to that of the adjacent supra-eyebrow and forehead defects. The scarring is acceptable with reliable and reproducible results. Oftentimes, sensory nerve branches can be preserved with careful planning and tedious dissection. This type of reconstruction should be considered in the armamentarium of supra-eyebrow and forehead defects.