Research
Original Investigation
Endoscopic Forehead Approach for Minimally Invasive Benign Tumor Excisions Haneen Sadick, MD; Michael Huber, MD; Stephen W. Perkins, MD; Heather H. Waters, MD; Grant S. Hamilton III; Ashley G. O’Reilly; Holger G. Gassner, MD
IMPORTANCE Direct transcutaneous resection has been a widely accepted standard for the
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removal of benign forehead lesions. In recent years, the endoscopic approach has become more prevalent because of its noninvasiveness. To date, only a few studies with limited case numbers have reported on this technique. We report our findings from one of the largest cohorts of patients undergoing tumor resection of the forehead via the endoscopic approach. OBJECTIVES To evaluate results of the endoscopic forehead approach for benign tumor excisions, to give a more nuanced insight into this procedure, and to discuss technical pearls and potential pitfalls from our experience. DESIGN, SETTING, AND PARTICIPANTS Multicenter, retrospective case study at 2 university centers and 1 private practice among 36 patients aged 18 to 72 years (mean age, 44 years) who underwent the endoscopic forehead approach for benign tumor resections. MAIN OUTCOMES AND MEASURES Symptoms at presentation, surgical procedure and duration, type of lesions, intraoperative and postoperative complications, recurrences, and patient satisfaction. RESULTS In total, 34 patients had an asymptomatic forehead mass, while 2 patients reported discomfort and headache. Among all patients, complete tumor excision was achieved endoscopically. The mean operative time was 36 minutes. Histopathological examination revealed 18 lipomas, 13 osteomas, 2 dermoid cysts, and 1 bone fragment after previous rhinoplasty. In 2 patients, no specimen was submitted. No hematomas, infections, scalp numbness, contour irregularities, temporal branch paralysis, or tumor recurrences occurred. One patient had a prolonged area of alopecia, which resolved on its own. All patients attested to a high satisfaction rate. CONCLUSIONS AND RELEVANCE The endoscopic approach offers excellent aesthetic results and allows for safe tumor removal. It has proven to be an effective and minimally invasive alternative to the conventional open approach. LEVEL OF EVIDENCE 4.
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Author Affiliations: Division of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology, University Hospital of Mannheim, Mannheim, Germany (Sadick); Division of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology, University Hospital of Regensburg, Regensburg, Germany (Huber, Gassner); Meridian Plastic Surgery Center, Indianapolis, Indiana (Perkins, Waters); Division of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota (Hamilton, O’Reilly). Corresponding Author: Haneen Sadick, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology, University Hospital of Mannheim, Theodor-Kutzer-Ufer, 68135 Mannheim, Germany (haneen.sadick @medma.uni-heidelberg.de). jamafacialplasticsurgery.com
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Endoscopic Forehead Approach
Original Investigation Research
T
he forehead is a frequent site of benign tumor occurrence, with osteoma most common, followed by lipoma.1 Osteomas are bone tumors, occurring most frequently in the facial skeleton.2,3 In the forehead region, they can be compact to spongy and are easily distinguishable from the underlying frontal bone.3 Clinically, a conspicuous cosmetic deformity can be a major patient concern. Lipomas are slow-growing soft tumors, generally encapsulated, solitary, and of rubbery consistency. Histopathological examination reveals adipocytes with various degrees of fibrosis. Multiple lesions are rare but are more common in young men.1 The clinical course is usually asymptomatic, but pain can be induced by nerve compression. Lipomas typically arise subcutaneously or over the periosteum in the subgaleal plane and tend to become quickly evident as an obvious mass.1 Other lesions in the differential diagnosis include epidermal or sebaceous cysts, hemangiomas, and liposarcomas. In addition to the appearance, confirmation of the working diagnosis is an important indication for the removal of benign forehead lesions.1,4 Multiple techniques for tumor excision of the forehead have been described. Direct tumor resection through the open coronal approach or a midforehead approach has been considered the gold standard. With the advent of the endoscope, less invasive surgical techniques have become available since the early 1990s.5 To date, only a few studies6-8 with limited case numbers have reported on the endoscopic approach for the excision of benign lesions of the forehead. The objective of this study was to report our findings from one of the largest cohorts of patients undergoing tumor resection of the forehead via the endoscopic approach to date. In total, 36 patients from 3 major facial plastic surgery centers were included. Based on analysis of the retrospective data, we evaluate results of the endoscopic forehead approach for benign tumor excisions, give a more nuanced insight into this procedure, and discuss technical pearls and potential pitfalls from our experience.
Methods Data collection for this multicenter study was approved by the institutional review board of the University of Regensburg and by the Mayo Clinic institutional review board. All patients gave their written informed consent for the endoscopic approach. This technique was explained in detail with possible risks and complications, including the option to convert to an open approach if needed. Data among 36 patients from 3 major facial plastic surgery centers were analyzed retrospectively. All patients underwent endoscopic resection of their forehead mass. The procedures were performed at the University Hospital of Regensburg, the Mayo Clinic, and the Meridian Plastic Surgery Center (Indianapolis, Indiana). Patients were identified from the medical records by selecting those with Current Procedural Terminology (CPT) code 21499 or International Classification of Diseases, Ninth Revision (ICD-9) code 213.0 (benign forehead mass, including bone removal); CPT codes 11420 through 11443; or ICD-9 code 214.0 (benign lesion excision, including margins, scalp, and face) dejamafacialplasticsurgery.com
Table 1. Main Outcome Measures Outcome Measure Patient-related data Demographics, sex, and age distribution Symptoms at presentation Location of the tumor Surgical data Surgical approach (endoscopic vs open), plane of dissection General or local anesthesia Histopathological findings (including size of the lesion) Duration of surgery (in minutes) Necessity of a drain Intraoperative and postoperative complications Inpatient or outpatient setting Postoperative follow-up data Last clinic visit Complications (eg, infection, hematoma, scalp numbness or pain, alopecia, or contour irregularities) Recurrences Patient satisfaction (based on the medical records)
pending on the tumor size. The medical records were then screened, and further review was performed only on those who had an endoscopic procedure performed. Review of the data was performed for patients treated between January 1, 1990, and December 31, 2012, at the Mayo Clinic and between January 1, 2009, and December 31, 2013, at the University Hospital of Regensburg and the Meridian Plastic Surgery Center. Table 1 summarizes the main outcome measures that were of specific interest. Altogether, the study included 26 women and 10 men. The mean patient age was 44 years (age range, 18-72 years).
Equipment A sheet retractor was mounted to a standard 4-mm rigid endoscope (18-cm length; Karl Storz GmbH & Co KG) with a 30° angled lens. For dissection, standard endoscopic elevators were used. For tumor dissection, endoscopic forceps, straight and curved elevators and rasps, a curved 6-mm osteotome, rightangled hooks, and in some osteoma cases a straight cutting and diamond burr were used. Bipolar cautery was used for hemostasis (Figure 1).
Surgical Technique For surgery, no hair was cut or shaved in any of the patients. The boundaries of the tumor were marked on the forehead with a skin marker and sometimes with percutaneous needles. Local anesthetic containing epinephrine was infiltrated along the incision lines and the forehead dissection area deep to the periosteal and subgaleal layers. Access incisions were typically placed behind the hairline. In large tumors of the forehead, 2 incisions were planned, one medial and the other parasagittal in line with the lateral limbus or at the level of the tumor. The incisions were made down to the bone through the galea aponeurotica and the periosteum. A small dissector was introduced to release the periosteum 3 cm around the ports and to create an optic space for JAMA Facial Plastic Surgery September/October 2014 Volume 16, Number 5
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the endoscope. The dissection planes of both ports were then joined together. Typically, the retractor-mounted endoscope was introduced through the incision on the surgeon’s nondominant side. The incision on the surgeon’s dominant side was used to insert the instruments. In smaller tumors of the forehead, a single transverse incision port of 2-cm to 3-cm length behind the hairline at the level of the tumor was sufficient to accommodate both the endoscope and the instrument (Figure 2). In patients with a soft-tissue mass (lipoma or dermoid cyst), 2 different techniques were performed. At the University Hospital of Regensburg and the Mayo Clinic, the tumor was first approached in a subperiosteal plane. After reaching the superior border of the mass, the periosteum was sharply incised, and a further blunt dissection of the tumor in the supraperiosteal and subgaleal plane was performed. At the Meridian Plastic Surgery Center, the soft-tissue lesions were primarily dissected in the subgaleal plane. If needed, the galea was then incised, and the tumor mass was bluntly mobilized. In patients with an osteoma, the tumor was approached at all 3 centers in a subperiosteal plane. Blunt dissection helped release the osteoma from the surrounding periosteum. If located in the upper half of the forehead, the osteoma was reFigure 1. Equipment
Shown is standard equipment for the endoscopic forehead approach.
moved with a straight bone chisel or a cutting burr. If located in the lower half of the forehead, the osteoma resection was performed with a slightly curved 6-mm osteotome and a curved rasp. The frontal bone surface was then smoothed with a rasp or a diamond burr and irrigated with saline solution to rinse off the remaining bone dust. The skin incisions were closed with sutures or staples, which were removed after 5 to 7 days. The operative site was compressed with folded gauze and an elastic head bandage to avoid entrapment of air or hematoma. In almost all cases, the resected specimens were sent for histopathological examination.
Results All patients were initially seen with a mass on their forehead that had slowly increased in size during several years before presentation. In 34 patients, the mass was asymptomatic. Two patients reported discomfort and increasing headache. The medical history was uneventful in 33 patients, but in 3 patients the mass had manifested 2 to 4 years after blunt trauma in the forehead region. Clinical examination revealed neither skin discoloration nor a tissue defect. None of the patients had a sensory disturbance. Figure 3 shows the location of the forehead lesions. All operations were performed using general anesthesia. In all patients, complete excision of the forehead mass was achieved by the endoscopic approach. In 20 patients, the encapsulated soft-tissue mass was resected after blunt dissection with complete mobilization and en bloc removal in the supraperiosteal or subgaleal plane (Figure 4; Video). Fourteen patients had a bony mass. In all patients, the mass was completely removed. In the upper half of the forehead, the masses were removed with a bone chisel and a burr; in the lower half of the forehead, the masses were removed with a curved 6-mm osteotome. In 9 patients, the wound surface was then smoothed with a rasp. In 5 patients in whom the bony mass was located near the hairline, a diamond burr was used. The mean operative time among all patients was 36 minutes from the initial skin incision to the final skin closure. The total operative time ranged from 12 to 52 minutes.
Figure 2. Endoscopic Forehead Approach for Benign Tumor Resection A
B
C
A, The medial and paramedial skin incisions are marked behind the frontal hairline. B, Both skin incisions are made down through the periosteal plane. C, After joining the dissection planes of both ports, the retractor-mounted endoscope is introduced through the medial port, and the elevator is introduced through the paramedial port.
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Endoscopic Forehead Approach
Original Investigation Research
Figure 3. Location of the Forehead Lesions
Central Right
Left 24
4
Upper half
16
31 7
5
21
35
29
9
10
17
1
3
15
2 9
11
27
13
Hairline
19 34
14 28
36 Lower half
18 6 12
22
23
8
30
25 32
20 26
Numerals 1 through 36 each indicate a patient. Histopathological findings are coded as yellow (lipoma), dark red (osteoma), light red (not sent), green (dermoid cyst), or blue (bone fragments).
Figure 4. Endoscopic Resection of a Forehead Lipoma A
B
C
D
A, Marking of the tumor boundaries on the forehead with percutaneous needles. B, Combined subperiosteal and subgaleal approach to reach the lipoma. C, Blunt dissection and resection of the lipoma. D, Dissection pocket after en bloc tumor removal.
Blood loss during the procedure was minimal in all patients, and the intraoperative and postoperative courses were uneventful. Histopathological examination revealed a lipoma in 18 patients, an osteoma in 13 patients, a dermoid cyst in 2 patients, and bone fragments in the midforehead and glabella region after previous rhinoplasty in 1 patient. In 2 patients, no specimen was submitted for histopathological examination. Table 2 lists detailed descriptions of the patient
profiles and histopathological findings. The mean size of the lipomas was 1.5 × 2.5 × 2.0 cm, and the mean size of the osteomas was 1.0 × 1.0 × 1.5 cm. No drains were used. None of the patients had noteworthy downtime following surgery. The patients in both US centers were treated as outpatients, whereas in the German center they were admitted for 1 night and then discharged.
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Table 2. Patient Profiles and Histopathological Findingsa Patient No./ Sex/Age, y
Histopathological Findings
Follow-up Period
1/F/72
Osteoma
6 mo
2/F/52
Not sent
1 mo
3/F/52
Osteoma
3 mo
4/M/64
Osteoma
3 mo
5/F/57
Osteoma
2 mo
6/F/50
Not sent
15 mo
7/F/42
Osteoma
3 mo
8/F/67
Osteoma
1 wk
9/F/48
Lipoma
2 mo
10/F/47
Lipoma
3 mo
11/M/53
Lipoma
1 wk
12/M/25
Lipoma
1 wk
13/F/20
Lipoma
2 mo
14/F/53
Osteoma
1 mo
15/F/43
Lipoma
1 mo
16/F/37
Lipoma
2 mo
17/F/36
Lipoma
1.5 mo
18/M/23
Lipoma
1d
19/F/29
Lipoma
42 mo
20/M/18
Dermoid cyst
27 mo
21/M/42
Lipoma
6 mo
22/M/45
Lipoma
24 mo
23/F/42
Osteoma
8 mo
24/F/61
Osteoma
18 mo
25/F/40
Dermoid cyst
12 mo
26/F/67
Bone fragments
9 mo
27/F/37
Lipoma
3 mo
28/F/40
Lipoma
1 mo
29/F/27
Lipoma
12 mo
30/M/46
Osteoma
18 mo
31/M/50
Osteoma
12 mo
32/F/35
Osteoma
15 mo
33/F/28
Lipoma
18 mo
34/F/58
Osteoma
11 mo
35/F/37
Lipoma
6 mo
36/M/44
Lipoma
3 wk
A
B
C
D
A and B, A 37-year-old patient (35 in Table 2) with a lipoma on her right forehead. C and D, A 44-year-old patient (36 in Table 2) with a lipoma on his right forehead. Shown are preoperative (A and C) and postoperative (B and D) views.
records, all 35 patients attested to a high satisfaction rate concerning cosmesis and no evidence of recurrences.
Discussion
Follow-up visits were attended by 35 of 36 patients. Patient 18 in Table 2 had traveled from abroad. After his discharge, he did not return to the center in which he had been operated on. Altogether, the mean follow-up period among all patients was 8 months (range, 1 day to 42 months). In the short term, no hematomas or infections were seen. Long-term follow-up examination revealed no signs of scalp numbness or temporal branch paralysis. One of 35 patients had a prolonged area of alopecia for 2 months, but this resolved on its own without the need for any further intervention. None of the patients reported any residual prominence on the forehead or contour irregularities. The incisions had healed adequately and were well hidden behind the anterior hairline. No scars were evident on the visible forehead (Figure 5). As documented in the medical
Endoscopic surgery is a well-established technique in facial plastic and reconstructive surgery.4,9 As a minimally invasive method, it has refined aesthetic procedures, such as foreheadlifting and brow-lifting.10,11 Studies12,13 have reported on its application in trauma surgery for frontal fracture reduction and fixation, as well as for skull contouring. In the literature, several cases of benign forehead lesions have been described. Direct tumor removal via an open approach through an overlying horizontal skin incision has been described as the classic method of resection.4,14,15 Inevitably, this method leaves a visible scar in patients who have primarily an asymptomatic clinical course.4 Liposuction has been proposed as an alternative treatment approach in lipomas.16,17 According to those studies, it is less invasive and minimizes the operative scar that can remain evident near the tumor boundary. As stated by Sakai et al,6 another disadvantage of liposuction may be that the lipoma is fragmented before histologic examination, increasing the risk of leaving tumor behind.
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a
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Figure 5. Two Representative Patients
There were no complications, except for patient 13, who had alopecia.
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Endoscopic Forehead Approach
Original Investigation Research
The endoscopic technique seems to be the best compromise as far as minimal invasiveness and safe tumor removal are concerned. Other than the percutaneous approach, the endoscopic approach has the main advantage of not leaving visible scars on the forehead, which is an important consideration for most patients. The incisions for the endoscopic forehead surgery are much smaller and are well hidden in the hair-bearing scalp.3 Kokoska et al18 and Cronin et al4 correctly point out that this technique is also applicable in men with a sparse or receding hairline but emphasize that future hairline changes might necessitate a more posteriorly placed incision. From our standpoint, an equally difficult situation is when the hairline is too high to place the endoscope through an incision posterior to the hairline. In such cases, we advise placing the endoscope through a small incision in an appropriate forehead crease along the relaxed skin tension lines or suggest using the direct transcutaneous approach. This situation is especially applicable in men having baldness with deep forehead creases. The location of the forehead tumors, as well as the shape of the forehead itself, may influence the choice of instruments. Tumors located in the upper half of the forehead can be reached faster and removed more easily with straight or curved elevators, blunt dissectors, bone chisels, and burrs. However, the use of a burr becomes more difficult if the tumors are located in the lower half of the forehead toward the supraorbital rim or in patients with a long convex shape of the forehead. These circumstances often necessitate a wider undermining of the forehead flap or a slightly longer scalp incision for better manipulation of instruments in the dissection pocket.3 In our patients with osteomas, a curved 6-mm osteotome helped us master these situations efficiently. By hitting the osteotome directly from superior to inferior or slightly angled, the bony lesion can be chipped off in one entire piece or in a piecemeal manner. To smooth the base, a rounded nasofrontal angle rasp was used. For lesions in the upper half of the forehead, we occasionally used a straight cutting and diamond burr to smooth the surface. The horizontal central third, with slightly more lesions occurring in the upper half of the forehead, was the most common site of forehead lesions in our series. From a technical point of view, improper positioning of the patient on the operating room table has a crucial effect on the surgical work flow, which occurs when the patient’s head is not placed as close to the head of the table as possible. It then becomes difficult to insert curved elevators into the incision because they may hit the table and impair the surgeon in his or her free radius of arm movement. An alternative option could be the use of a Mayfield headrest. The endoscopic-assisted dissection itself is easily performed in a blunt fashion along the subperiosteal and subgaleal plane by dividing the tissue layers with the sheet retractor and elevators. This can be facilitated by placing the local anesthetic infiltration along the subperiosteal and subgaleal planes, with consecutive hydrodissection of the path to the lesion. With its magnification, the 30° endoscope provides enhanced visualization of the operative field, with excellent identification of the anatomic and pathologic structures. The surgeon creates a limited dissection pocket, which helps mini-
mize the risk of bleeding, hematoma, and infection.4,19 Moreover, trainees and medical students have the opportunity to observe every step of the surgery on the video screen. These real-time images can be recorded, helping teach the surgical anatomy and technique retrospectively.2 Soft-tissue lesions can be approached in 2 ways: through the subgaleal plane alone or through a combined subperiosteal and subgaleal approach. Advocates of the combined approach argue that it allows for quick, safe, and bloodless dissection and efficient illumination in the subperiosteal plane.3,19 The superficial divisions of the supraorbital and supratrochlear nerves run superficial to the frontalis muscle, and the deep division of the supraorbital nerve runs between the galea aponeurotica and the periosteum, medial to and parallel to the superior temporal line. Therefore, a subperiosteal dissection plane helps protect the deep branch of the supraorbital nerve that traverses the subgaleal plane and may more reliably preserve the subgaleal blood supply to the scalp.15,20 After entering the subperiosteal pocket, the soft-tissue mass overlying the intact periosteum is visualized. This is done by palpation of the mass and by percutaneous marking of the superior tumor border with needles. The periosteum is incised along the marking, and the soft-tissue mass is exposed with blunt dissection under simultaneous endoscopic and external visualization. This technique has proved successful in other studies.2,19 After removal of the mass, the dissection pocket is inspected for bleeding, and bipolar hemostasis is obtained, taking care to avoid the hair follicles. The subgaleal plane of dissection alone also has distinct advantages, which is especially evident in lipoma cases. The reason lies in the anatomy and their location. Although lipomas are mainly located between the periosteum and the galea, they can also be found superficial to the galea within the frontalis muscle.1 In cases with a superficial location to the galea, we recommend careful incision through the galea without injuring the tumor, which enables blunt en bloc tumor removal. The main advantage of a subgaleal approach as the initial plane of dissection is the possibility of bidirectional tumor removal below or above the galea. We concur that both approaches are equally safe and effective in the hands of experienced surgeons. To reduce the number of scars over the scalp and to minimize the risk of alopecia, a single-port approach can be chosen instead of a 2-port approach. This approach applies to tumor masses that are located in the middle third of the forehead. In such cases, a single horizontal scalp incision can be used, oriented transversely with respect to the anterior hairline.21 Recurrences must be considered, especially in the case of soft-tissue lesions. However, complete en bloc tumor removal should minimize this risk. No recurrences were observed in the present study. However, this study is limited by its retrospective nature. Further additional prospective studies for evaluation of the long-term results in more patients are desirable.
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Conclusions An endoscopic approach for the removal of tumors of the forehead has proved to be an effective and minimally invasive al-
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ternative to the conventional open approach. Placement of the incision in the hair-bearing scalp is ideal, especially in patients who have a predisposition to skin pigment changes, ke-
ARTICLE INFORMATION Accepted for Publication: April 7, 2014. Published Online: June 19, 2014. doi:10.1001/jamafacial.2014.269. Author Contributions: Dr Sadick had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Sadick, Gassner. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Sadick, Perkins, Hamilton, Gassner. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Sadick. Study supervision: Gassner. Conflict of Interest Disclosures: None reported. Previous Presentations: This study was presented at the American Academy of Facial Plastic and Reconstructive Surgery 11th International Symposium of Facial Plastic Surgery in collaboration with the International Federation of Facial Plastic Surgery Societies; May 28, 2014; New York, New York; and at the course “Finesse in Facial Plastic Surgery”; October 10, 2013; Regensburg, Germany. REFERENCES 1. Wörle B, Kunte C, Schaller M, Konz B. Lipoma of the forehead [in German]. Hautarzt. 2000;51(9): 661-665.
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loid formation, or hypertrophic scarring or in patients who want to avoid all visible scars, It offers excellent cosmetic results and allows for safe tumor excision.
2. Meningaud JP, Toure G, Lantieri L. Endoscopic resection of osteoma of the forehead. Scand J Plast Reconstr Surg Hand Surg. 2008;42(6):286-289.
12. Onishi K, Maruyama Y, Sawaizumi M. Use of endoscopic surgery for forehead recontouring. Plast Reconstr Surg. 1997;100:1327-1332.
3. Mun GH, Jung ES, Lim SY, Hyon WS, Bang SI, Oh KS. Excision of forehead osteomas: experience with 12 patients with use of an endoscopic technique. J Craniofac Surg. 2006;17(3):426-430.
13. Lappert PW, Lee JW. Treatment of an isolated outer table frontal sinus fracture using endoscopic reduction and fixation. Plast Reconstr Surg. 1998; 102(5):1642-1645.
4. Cronin ED, Ruiz-Razura A, Livingston CK, Katzen JT. Endoscopic approach for the resection of forehead masses. Plast Reconstr Surg. 2000;105(7): 2459-2463.
14. Patel TR, Borah GL. Frontal bone periosteal osteomas. Plast Reconstr Surg. 2004;114(3):648-651.
5. Ramirez OM. Endoscopic subperiosteal browlift and facelift. Clin Plast Surg. 1995;22(4):639-660.
15. Funayama E, Minakawa H, Oyama A. Forehead lipoma resection via a small remote incision using a surgical raspatory. J Am Acad Dermatol. 2007;56 (3):458-459.
6. Sakai Y, Okazaki M, Kobayashi S, Ohmori K. Endoscopic excision of large capsulated lipomas. Br J Plast Surg. 1996;49(4):228-232.
16. Rubenstein R, Roenigk HH Jr, Garden JM, Goldberg NS, Pinski JB. Liposuction for lipomas. J Dermatol Surg Oncol. 1985;11(11):1070-1074.
7. Pozner JN, Canick ML, Ramirez OM. Endoscopically assisted lipoma removal. Plast Reconstr Surg. 1996;98(2):376-377.
17. Nichter LS, Gupta BR. Liposuction of giant lipoma. Ann Plast Surg. 1990;24(4):362-365.
8. Lin SD, Lee SS, Chang KP, Lin TM, Lu DK, Tsai CC. Endoscopic excision of benign tumors in the forehead and brow. Ann Plast Surg. 2001;46(1):1-4.
18. Kokoska MS, Branham GH, Hamilton MM, Thomas JR. Endoscopic excision of a forehead mass. Arch Otolaryngol Head Neck Surg. 1997;123 (8):815-817.
9. Ramirez OM. Endoscopic techniques in facial rejuvenation: an overview, part I. Aesthetic Plast Surg. 1994;18(2):141-147.
19. de Chalain T, Tan B. Ivory osteoma of the craniofacial skeleton. J Craniofac Surg. 2003;14(5): 729-735.
10. Daniel RK, Tirkanits B. Endoscopic forehead lift: aesthetics and analysis. Clin Plast Surg. 1995;22(4): 605-618.
20. Knize DM. Reassessment of the coronal incision and subgaleal dissection for foreheadplasty. Plast Reconstr Surg. 1998;102(2):478-492.
11. Paige KT, Eaves FF III, Wood RJ. Endoscopically assisted plastic surgical procedures in the pediatric patient. J Craniofac Surg. 1997;8(3):164-169.
21. Goh LHT, Tan BK, Liam FC. Endoscopic resection of forehead lipoma: a subperiosteal single-portal approach. Indian J Plast Surg. 2008;41(2):141-144.
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Original Investigation
Endoscopic Forehead Approach for Minimally Invasive Benign Tumor Excisions Haneen Sadick, MD; Michael Huber, MD; Stephen W. Perkins, MD; Heather H. Waters, MD; Grant S. Hamilton III; Ashley G. O’Reilly; Holger G. Gassner, MD
IMPORTANCE Direct transcutaneous resection has been a widely accepted standard for the
Video at jamafacialplasticsurgery.com
removal of benign forehead lesions. In recent years, the endoscopic approach has become more prevalent because of its noninvasiveness. To date, only a few studies with limited case numbers have reported on this technique. We report our findings from one of the largest cohorts of patients undergoing tumor resection of the forehead via the endoscopic approach. OBJECTIVES To evaluate results of the endoscopic forehead approach for benign tumor excisions, to give a more nuanced insight into this procedure, and to discuss technical pearls and potential pitfalls from our experience. DESIGN, SETTING, AND PARTICIPANTS Multicenter, retrospective case study at 2 university centers and 1 private practice among 36 patients aged 18 to 72 years (mean age, 44 years) who underwent the endoscopic forehead approach for benign tumor resections. MAIN OUTCOMES AND MEASURES Symptoms at presentation, surgical procedure and duration, type of lesions, intraoperative and postoperative complications, recurrences, and patient satisfaction. RESULTS In total, 34 patients had an asymptomatic forehead mass, while 2 patients reported discomfort and headache. Among all patients, complete tumor excision was achieved endoscopically. The mean operative time was 36 minutes. Histopathological examination revealed 18 lipomas, 13 osteomas, 2 dermoid cysts, and 1 bone fragment after previous rhinoplasty. In 2 patients, no specimen was submitted. No hematomas, infections, scalp numbness, contour irregularities, temporal branch paralysis, or tumor recurrences occurred. One patient had a prolonged area of alopecia, which resolved on its own. All patients attested to a high satisfaction rate. CONCLUSIONS AND RELEVANCE The endoscopic approach offers excellent aesthetic results and allows for safe tumor removal. It has proven to be an effective and minimally invasive alternative to the conventional open approach. LEVEL OF EVIDENCE 4.
JAMA Facial Plast Surg. 2014;16(5):352-358. doi:10.1001/jamafacial.2014.269 Published online June 19, 2014. 352
Author Affiliations: Division of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology, University Hospital of Mannheim, Mannheim, Germany (Sadick); Division of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology, University Hospital of Regensburg, Regensburg, Germany (Huber, Gassner); Meridian Plastic Surgery Center, Indianapolis, Indiana (Perkins, Waters); Division of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota (Hamilton, O’Reilly). Corresponding Author: Haneen Sadick, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology, University Hospital of Mannheim, Theodor-Kutzer-Ufer, 68135 Mannheim, Germany (haneen.sadick @medma.uni-heidelberg.de). jamafacialplasticsurgery.com
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T
he forehead is a frequent site of benign tumor occurrence, with osteoma most common, followed by lipoma.1 Osteomas are bone tumors, occurring most frequently in the facial skeleton.2,3 In the forehead region, they can be compact to spongy and are easily distinguishable from the underlying frontal bone.3 Clinically, a conspicuous cosmetic deformity can be a major patient concern. Lipomas are slow-growing soft tumors, generally encapsulated, solitary, and of rubbery consistency. Histopathological examination reveals adipocytes with various degrees of fibrosis. Multiple lesions are rare but are more common in young men.1 The clinical course is usually asymptomatic, but pain can be induced by nerve compression. Lipomas typically arise subcutaneously or over the periosteum in the subgaleal plane and tend to become quickly evident as an obvious mass.1 Other lesions in the differential diagnosis include epidermal or sebaceous cysts, hemangiomas, and liposarcomas. In addition to the appearance, confirmation of the working diagnosis is an important indication for the removal of benign forehead lesions.1,4 Multiple techniques for tumor excision of the forehead have been described. Direct tumor resection through the open coronal approach or a midforehead approach has been considered the gold standard. With the advent of the endoscope, less invasive surgical techniques have become available since the early 1990s.5 To date, only a few studies6-8 with limited case numbers have reported on the endoscopic approach for the excision of benign lesions of the forehead. The objective of this study was to report our findings from one of the largest cohorts of patients undergoing tumor resection of the forehead via the endoscopic approach to date. In total, 36 patients from 3 major facial plastic surgery centers were included. Based on analysis of the retrospective data, we evaluate results of the endoscopic forehead approach for benign tumor excisions, give a more nuanced insight into this procedure, and discuss technical pearls and potential pitfalls from our experience.
Methods Data collection for this multicenter study was approved by the institutional review board of the University of Regensburg and by the Mayo Clinic institutional review board. All patients gave their written informed consent for the endoscopic approach. This technique was explained in detail with possible risks and complications, including the option to convert to an open approach if needed. Data among 36 patients from 3 major facial plastic surgery centers were analyzed retrospectively. All patients underwent endoscopic resection of their forehead mass. The procedures were performed at the University Hospital of Regensburg, the Mayo Clinic, and the Meridian Plastic Surgery Center (Indianapolis, Indiana). Patients were identified from the medical records by selecting those with Current Procedural Terminology (CPT) code 21499 or International Classification of Diseases, Ninth Revision (ICD-9) code 213.0 (benign forehead mass, including bone removal); CPT codes 11420 through 11443; or ICD-9 code 214.0 (benign lesion excision, including margins, scalp, and face) dejamafacialplasticsurgery.com
Table 1. Main Outcome Measures Outcome Measure Patient-related data Demographics, sex, and age distribution Symptoms at presentation Location of the tumor Surgical data Surgical approach (endoscopic vs open), plane of dissection General or local anesthesia Histopathological findings (including size of the lesion) Duration of surgery (in minutes) Necessity of a drain Intraoperative and postoperative complications Inpatient or outpatient setting Postoperative follow-up data Last clinic visit Complications (eg, infection, hematoma, scalp numbness or pain, alopecia, or contour irregularities) Recurrences Patient satisfaction (based on the medical records)
pending on the tumor size. The medical records were then screened, and further review was performed only on those who had an endoscopic procedure performed. Review of the data was performed for patients treated between January 1, 1990, and December 31, 2012, at the Mayo Clinic and between January 1, 2009, and December 31, 2013, at the University Hospital of Regensburg and the Meridian Plastic Surgery Center. Table 1 summarizes the main outcome measures that were of specific interest. Altogether, the study included 26 women and 10 men. The mean patient age was 44 years (age range, 18-72 years).
Equipment A sheet retractor was mounted to a standard 4-mm rigid endoscope (18-cm length; Karl Storz GmbH & Co KG) with a 30° angled lens. For dissection, standard endoscopic elevators were used. For tumor dissection, endoscopic forceps, straight and curved elevators and rasps, a curved 6-mm osteotome, rightangled hooks, and in some osteoma cases a straight cutting and diamond burr were used. Bipolar cautery was used for hemostasis (Figure 1).
Surgical Technique For surgery, no hair was cut or shaved in any of the patients. The boundaries of the tumor were marked on the forehead with a skin marker and sometimes with percutaneous needles. Local anesthetic containing epinephrine was infiltrated along the incision lines and the forehead dissection area deep to the periosteal and subgaleal layers. Access incisions were typically placed behind the hairline. In large tumors of the forehead, 2 incisions were planned, one medial and the other parasagittal in line with the lateral limbus or at the level of the tumor. The incisions were made down to the bone through the galea aponeurotica and the periosteum. A small dissector was introduced to release the periosteum 3 cm around the ports and to create an optic space for JAMA Facial Plastic Surgery September/October 2014 Volume 16, Number 5
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the endoscope. The dissection planes of both ports were then joined together. Typically, the retractor-mounted endoscope was introduced through the incision on the surgeon’s nondominant side. The incision on the surgeon’s dominant side was used to insert the instruments. In smaller tumors of the forehead, a single transverse incision port of 2-cm to 3-cm length behind the hairline at the level of the tumor was sufficient to accommodate both the endoscope and the instrument (Figure 2). In patients with a soft-tissue mass (lipoma or dermoid cyst), 2 different techniques were performed. At the University Hospital of Regensburg and the Mayo Clinic, the tumor was first approached in a subperiosteal plane. After reaching the superior border of the mass, the periosteum was sharply incised, and a further blunt dissection of the tumor in the supraperiosteal and subgaleal plane was performed. At the Meridian Plastic Surgery Center, the soft-tissue lesions were primarily dissected in the subgaleal plane. If needed, the galea was then incised, and the tumor mass was bluntly mobilized. In patients with an osteoma, the tumor was approached at all 3 centers in a subperiosteal plane. Blunt dissection helped release the osteoma from the surrounding periosteum. If located in the upper half of the forehead, the osteoma was reFigure 1. Equipment
Shown is standard equipment for the endoscopic forehead approach.
moved with a straight bone chisel or a cutting burr. If located in the lower half of the forehead, the osteoma resection was performed with a slightly curved 6-mm osteotome and a curved rasp. The frontal bone surface was then smoothed with a rasp or a diamond burr and irrigated with saline solution to rinse off the remaining bone dust. The skin incisions were closed with sutures or staples, which were removed after 5 to 7 days. The operative site was compressed with folded gauze and an elastic head bandage to avoid entrapment of air or hematoma. In almost all cases, the resected specimens were sent for histopathological examination.
Results All patients were initially seen with a mass on their forehead that had slowly increased in size during several years before presentation. In 34 patients, the mass was asymptomatic. Two patients reported discomfort and increasing headache. The medical history was uneventful in 33 patients, but in 3 patients the mass had manifested 2 to 4 years after blunt trauma in the forehead region. Clinical examination revealed neither skin discoloration nor a tissue defect. None of the patients had a sensory disturbance. Figure 3 shows the location of the forehead lesions. All operations were performed using general anesthesia. In all patients, complete excision of the forehead mass was achieved by the endoscopic approach. In 20 patients, the encapsulated soft-tissue mass was resected after blunt dissection with complete mobilization and en bloc removal in the supraperiosteal or subgaleal plane (Figure 4; Video). Fourteen patients had a bony mass. In all patients, the mass was completely removed. In the upper half of the forehead, the masses were removed with a bone chisel and a burr; in the lower half of the forehead, the masses were removed with a curved 6-mm osteotome. In 9 patients, the wound surface was then smoothed with a rasp. In 5 patients in whom the bony mass was located near the hairline, a diamond burr was used. The mean operative time among all patients was 36 minutes from the initial skin incision to the final skin closure. The total operative time ranged from 12 to 52 minutes.
Figure 2. Endoscopic Forehead Approach for Benign Tumor Resection A
B
C
A, The medial and paramedial skin incisions are marked behind the frontal hairline. B, Both skin incisions are made down through the periosteal plane. C, After joining the dissection planes of both ports, the retractor-mounted endoscope is introduced through the medial port, and the elevator is introduced through the paramedial port.
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Original Investigation Research
Figure 3. Location of the Forehead Lesions
Central Right
Left 24
4
Upper half
16
31 7
5
21
35
29
9
10
17
1
3
15
2 9
11
27
13
Hairline
19 34
14 28
36 Lower half
18 6 12
22
23
8
30
25 32
20 26
Numerals 1 through 36 each indicate a patient. Histopathological findings are coded as yellow (lipoma), dark red (osteoma), light red (not sent), green (dermoid cyst), or blue (bone fragments).
Figure 4. Endoscopic Resection of a Forehead Lipoma A
B
C
D
A, Marking of the tumor boundaries on the forehead with percutaneous needles. B, Combined subperiosteal and subgaleal approach to reach the lipoma. C, Blunt dissection and resection of the lipoma. D, Dissection pocket after en bloc tumor removal.
Blood loss during the procedure was minimal in all patients, and the intraoperative and postoperative courses were uneventful. Histopathological examination revealed a lipoma in 18 patients, an osteoma in 13 patients, a dermoid cyst in 2 patients, and bone fragments in the midforehead and glabella region after previous rhinoplasty in 1 patient. In 2 patients, no specimen was submitted for histopathological examination. Table 2 lists detailed descriptions of the patient
profiles and histopathological findings. The mean size of the lipomas was 1.5 × 2.5 × 2.0 cm, and the mean size of the osteomas was 1.0 × 1.0 × 1.5 cm. No drains were used. None of the patients had noteworthy downtime following surgery. The patients in both US centers were treated as outpatients, whereas in the German center they were admitted for 1 night and then discharged.
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Table 2. Patient Profiles and Histopathological Findingsa Patient No./ Sex/Age, y
Histopathological Findings
Follow-up Period
1/F/72
Osteoma
6 mo
2/F/52
Not sent
1 mo
3/F/52
Osteoma
3 mo
4/M/64
Osteoma
3 mo
5/F/57
Osteoma
2 mo
6/F/50
Not sent
15 mo
7/F/42
Osteoma
3 mo
8/F/67
Osteoma
1 wk
9/F/48
Lipoma
2 mo
10/F/47
Lipoma
3 mo
11/M/53
Lipoma
1 wk
12/M/25
Lipoma
1 wk
13/F/20
Lipoma
2 mo
14/F/53
Osteoma
1 mo
15/F/43
Lipoma
1 mo
16/F/37
Lipoma
2 mo
17/F/36
Lipoma
1.5 mo
18/M/23
Lipoma
1d
19/F/29
Lipoma
42 mo
20/M/18
Dermoid cyst
27 mo
21/M/42
Lipoma
6 mo
22/M/45
Lipoma
24 mo
23/F/42
Osteoma
8 mo
24/F/61
Osteoma
18 mo
25/F/40
Dermoid cyst
12 mo
26/F/67
Bone fragments
9 mo
27/F/37
Lipoma
3 mo
28/F/40
Lipoma
1 mo
29/F/27
Lipoma
12 mo
30/M/46
Osteoma
18 mo
31/M/50
Osteoma
12 mo
32/F/35
Osteoma
15 mo
33/F/28
Lipoma
18 mo
34/F/58
Osteoma
11 mo
35/F/37
Lipoma
6 mo
36/M/44
Lipoma
3 wk
A
B
C
D
A and B, A 37-year-old patient (35 in Table 2) with a lipoma on her right forehead. C and D, A 44-year-old patient (36 in Table 2) with a lipoma on his right forehead. Shown are preoperative (A and C) and postoperative (B and D) views.
records, all 35 patients attested to a high satisfaction rate concerning cosmesis and no evidence of recurrences.
Discussion
Follow-up visits were attended by 35 of 36 patients. Patient 18 in Table 2 had traveled from abroad. After his discharge, he did not return to the center in which he had been operated on. Altogether, the mean follow-up period among all patients was 8 months (range, 1 day to 42 months). In the short term, no hematomas or infections were seen. Long-term follow-up examination revealed no signs of scalp numbness or temporal branch paralysis. One of 35 patients had a prolonged area of alopecia for 2 months, but this resolved on its own without the need for any further intervention. None of the patients reported any residual prominence on the forehead or contour irregularities. The incisions had healed adequately and were well hidden behind the anterior hairline. No scars were evident on the visible forehead (Figure 5). As documented in the medical
Endoscopic surgery is a well-established technique in facial plastic and reconstructive surgery.4,9 As a minimally invasive method, it has refined aesthetic procedures, such as foreheadlifting and brow-lifting.10,11 Studies12,13 have reported on its application in trauma surgery for frontal fracture reduction and fixation, as well as for skull contouring. In the literature, several cases of benign forehead lesions have been described. Direct tumor removal via an open approach through an overlying horizontal skin incision has been described as the classic method of resection.4,14,15 Inevitably, this method leaves a visible scar in patients who have primarily an asymptomatic clinical course.4 Liposuction has been proposed as an alternative treatment approach in lipomas.16,17 According to those studies, it is less invasive and minimizes the operative scar that can remain evident near the tumor boundary. As stated by Sakai et al,6 another disadvantage of liposuction may be that the lipoma is fragmented before histologic examination, increasing the risk of leaving tumor behind.
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Figure 5. Two Representative Patients
There were no complications, except for patient 13, who had alopecia.
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Original Investigation Research
The endoscopic technique seems to be the best compromise as far as minimal invasiveness and safe tumor removal are concerned. Other than the percutaneous approach, the endoscopic approach has the main advantage of not leaving visible scars on the forehead, which is an important consideration for most patients. The incisions for the endoscopic forehead surgery are much smaller and are well hidden in the hair-bearing scalp.3 Kokoska et al18 and Cronin et al4 correctly point out that this technique is also applicable in men with a sparse or receding hairline but emphasize that future hairline changes might necessitate a more posteriorly placed incision. From our standpoint, an equally difficult situation is when the hairline is too high to place the endoscope through an incision posterior to the hairline. In such cases, we advise placing the endoscope through a small incision in an appropriate forehead crease along the relaxed skin tension lines or suggest using the direct transcutaneous approach. This situation is especially applicable in men having baldness with deep forehead creases. The location of the forehead tumors, as well as the shape of the forehead itself, may influence the choice of instruments. Tumors located in the upper half of the forehead can be reached faster and removed more easily with straight or curved elevators, blunt dissectors, bone chisels, and burrs. However, the use of a burr becomes more difficult if the tumors are located in the lower half of the forehead toward the supraorbital rim or in patients with a long convex shape of the forehead. These circumstances often necessitate a wider undermining of the forehead flap or a slightly longer scalp incision for better manipulation of instruments in the dissection pocket.3 In our patients with osteomas, a curved 6-mm osteotome helped us master these situations efficiently. By hitting the osteotome directly from superior to inferior or slightly angled, the bony lesion can be chipped off in one entire piece or in a piecemeal manner. To smooth the base, a rounded nasofrontal angle rasp was used. For lesions in the upper half of the forehead, we occasionally used a straight cutting and diamond burr to smooth the surface. The horizontal central third, with slightly more lesions occurring in the upper half of the forehead, was the most common site of forehead lesions in our series. From a technical point of view, improper positioning of the patient on the operating room table has a crucial effect on the surgical work flow, which occurs when the patient’s head is not placed as close to the head of the table as possible. It then becomes difficult to insert curved elevators into the incision because they may hit the table and impair the surgeon in his or her free radius of arm movement. An alternative option could be the use of a Mayfield headrest. The endoscopic-assisted dissection itself is easily performed in a blunt fashion along the subperiosteal and subgaleal plane by dividing the tissue layers with the sheet retractor and elevators. This can be facilitated by placing the local anesthetic infiltration along the subperiosteal and subgaleal planes, with consecutive hydrodissection of the path to the lesion. With its magnification, the 30° endoscope provides enhanced visualization of the operative field, with excellent identification of the anatomic and pathologic structures. The surgeon creates a limited dissection pocket, which helps mini-
mize the risk of bleeding, hematoma, and infection.4,19 Moreover, trainees and medical students have the opportunity to observe every step of the surgery on the video screen. These real-time images can be recorded, helping teach the surgical anatomy and technique retrospectively.2 Soft-tissue lesions can be approached in 2 ways: through the subgaleal plane alone or through a combined subperiosteal and subgaleal approach. Advocates of the combined approach argue that it allows for quick, safe, and bloodless dissection and efficient illumination in the subperiosteal plane.3,19 The superficial divisions of the supraorbital and supratrochlear nerves run superficial to the frontalis muscle, and the deep division of the supraorbital nerve runs between the galea aponeurotica and the periosteum, medial to and parallel to the superior temporal line. Therefore, a subperiosteal dissection plane helps protect the deep branch of the supraorbital nerve that traverses the subgaleal plane and may more reliably preserve the subgaleal blood supply to the scalp.15,20 After entering the subperiosteal pocket, the soft-tissue mass overlying the intact periosteum is visualized. This is done by palpation of the mass and by percutaneous marking of the superior tumor border with needles. The periosteum is incised along the marking, and the soft-tissue mass is exposed with blunt dissection under simultaneous endoscopic and external visualization. This technique has proved successful in other studies.2,19 After removal of the mass, the dissection pocket is inspected for bleeding, and bipolar hemostasis is obtained, taking care to avoid the hair follicles. The subgaleal plane of dissection alone also has distinct advantages, which is especially evident in lipoma cases. The reason lies in the anatomy and their location. Although lipomas are mainly located between the periosteum and the galea, they can also be found superficial to the galea within the frontalis muscle.1 In cases with a superficial location to the galea, we recommend careful incision through the galea without injuring the tumor, which enables blunt en bloc tumor removal. The main advantage of a subgaleal approach as the initial plane of dissection is the possibility of bidirectional tumor removal below or above the galea. We concur that both approaches are equally safe and effective in the hands of experienced surgeons. To reduce the number of scars over the scalp and to minimize the risk of alopecia, a single-port approach can be chosen instead of a 2-port approach. This approach applies to tumor masses that are located in the middle third of the forehead. In such cases, a single horizontal scalp incision can be used, oriented transversely with respect to the anterior hairline.21 Recurrences must be considered, especially in the case of soft-tissue lesions. However, complete en bloc tumor removal should minimize this risk. No recurrences were observed in the present study. However, this study is limited by its retrospective nature. Further additional prospective studies for evaluation of the long-term results in more patients are desirable.
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Conclusions An endoscopic approach for the removal of tumors of the forehead has proved to be an effective and minimally invasive al-
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ternative to the conventional open approach. Placement of the incision in the hair-bearing scalp is ideal, especially in patients who have a predisposition to skin pigment changes, ke-
ARTICLE INFORMATION Accepted for Publication: April 7, 2014. Published Online: June 19, 2014. doi:10.1001/jamafacial.2014.269. Author Contributions: Dr Sadick had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Sadick, Gassner. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Sadick, Perkins, Hamilton, Gassner. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Sadick. Study supervision: Gassner. Conflict of Interest Disclosures: None reported. Previous Presentations: This study was presented at the American Academy of Facial Plastic and Reconstructive Surgery 11th International Symposium of Facial Plastic Surgery in collaboration with the International Federation of Facial Plastic Surgery Societies; May 28, 2014; New York, New York; and at the course “Finesse in Facial Plastic Surgery”; October 10, 2013; Regensburg, Germany. REFERENCES 1. Wörle B, Kunte C, Schaller M, Konz B. Lipoma of the forehead [in German]. Hautarzt. 2000;51(9): 661-665.
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loid formation, or hypertrophic scarring or in patients who want to avoid all visible scars, It offers excellent cosmetic results and allows for safe tumor excision.
2. Meningaud JP, Toure G, Lantieri L. Endoscopic resection of osteoma of the forehead. Scand J Plast Reconstr Surg Hand Surg. 2008;42(6):286-289.
12. Onishi K, Maruyama Y, Sawaizumi M. Use of endoscopic surgery for forehead recontouring. Plast Reconstr Surg. 1997;100:1327-1332.
3. Mun GH, Jung ES, Lim SY, Hyon WS, Bang SI, Oh KS. Excision of forehead osteomas: experience with 12 patients with use of an endoscopic technique. J Craniofac Surg. 2006;17(3):426-430.
13. Lappert PW, Lee JW. Treatment of an isolated outer table frontal sinus fracture using endoscopic reduction and fixation. Plast Reconstr Surg. 1998; 102(5):1642-1645.
4. Cronin ED, Ruiz-Razura A, Livingston CK, Katzen JT. Endoscopic approach for the resection of forehead masses. Plast Reconstr Surg. 2000;105(7): 2459-2463.
14. Patel TR, Borah GL. Frontal bone periosteal osteomas. Plast Reconstr Surg. 2004;114(3):648-651.
5. Ramirez OM. Endoscopic subperiosteal browlift and facelift. Clin Plast Surg. 1995;22(4):639-660.
15. Funayama E, Minakawa H, Oyama A. Forehead lipoma resection via a small remote incision using a surgical raspatory. J Am Acad Dermatol. 2007;56 (3):458-459.
6. Sakai Y, Okazaki M, Kobayashi S, Ohmori K. Endoscopic excision of large capsulated lipomas. Br J Plast Surg. 1996;49(4):228-232.
16. Rubenstein R, Roenigk HH Jr, Garden JM, Goldberg NS, Pinski JB. Liposuction for lipomas. J Dermatol Surg Oncol. 1985;11(11):1070-1074.
7. Pozner JN, Canick ML, Ramirez OM. Endoscopically assisted lipoma removal. Plast Reconstr Surg. 1996;98(2):376-377.
17. Nichter LS, Gupta BR. Liposuction of giant lipoma. Ann Plast Surg. 1990;24(4):362-365.
8. Lin SD, Lee SS, Chang KP, Lin TM, Lu DK, Tsai CC. Endoscopic excision of benign tumors in the forehead and brow. Ann Plast Surg. 2001;46(1):1-4.
18. Kokoska MS, Branham GH, Hamilton MM, Thomas JR. Endoscopic excision of a forehead mass. Arch Otolaryngol Head Neck Surg. 1997;123 (8):815-817.
9. Ramirez OM. Endoscopic techniques in facial rejuvenation: an overview, part I. Aesthetic Plast Surg. 1994;18(2):141-147.
19. de Chalain T, Tan B. Ivory osteoma of the craniofacial skeleton. J Craniofac Surg. 2003;14(5): 729-735.
10. Daniel RK, Tirkanits B. Endoscopic forehead lift: aesthetics and analysis. Clin Plast Surg. 1995;22(4): 605-618.
20. Knize DM. Reassessment of the coronal incision and subgaleal dissection for foreheadplasty. Plast Reconstr Surg. 1998;102(2):478-492.
11. Paige KT, Eaves FF III, Wood RJ. Endoscopically assisted plastic surgical procedures in the pediatric patient. J Craniofac Surg. 1997;8(3):164-169.
21. Goh LHT, Tan BK, Liam FC. Endoscopic resection of forehead lipoma: a subperiosteal single-portal approach. Indian J Plast Surg. 2008;41(2):141-144.
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