Q: Dr. Eppley, I am a 22 year old female who underwent a forehead lipoma removal by a neurosurgeon two years ago. He did a bicoronal flap and a small frontal craniotomy because part of the lesion that was tethered in the bone and he didn’t want to just pull it for fear of intracranial extension. The pathology showed it was a lipoma and I now have plate and screws in the forehead which are palpable. I now have a 3cm x 3cm area in the middle of my forehead that is excess tissue where the lipoma was. It is basically a balloon (hollow) with slightly thinner skin. I attached some photos.
My surgeon gave me the following options for correction:
1) A hairline incision appraoch but that would pull my already normal brows up.
2) A bicoronal incision would already raise my already high forehead and pull my brows up.
3) A direct horizontal incision (I have no forehead rythids) but maybe this is the best option and I have to settle for a scar? If I have a direct excision it gives my surgeon the advantage to go subperiosteal and remove the plate which is palpable.
I am stuck in terms of knowing what to do and would really appreciate your opinion!
A: The simple answer to your case is why don’t you just do a bicoronal incisional approach? You already have the scar and a bicoronal flap does not raise up the eyebrows unless scalp skin is removed and that is the intent of the procedure. This will provide a direct approach to removing the plates and screws and possibly filling in the craniotomy defect/irregularities with hydroxyapatite cement.
I would never do a hairline incision when a bicoronal incision exists behind it. You have no way of knowing how well the vascular inflow to the intervening skin segment between the two incisions is and there is a real risk of scalp necrosis.
For a cosmetic forehead problem in a young woman, it would be a near surgical crime to put a horizontal scar on your forehead, trading off one cosmetic problem for another…and the scar will likely look worse than what you have now. This would be particularly egregious when a bicoronal scalp scar already exists and there are no cosmetic trade-offs for using it.
Dr. Barry Eppley