The Cruciate Flap: A novel use of dual opposing A-to-T flaps for a Mohs defect of the mid-brow and forehead
Abstract
Introduction: Defects involving multiple cosmetic subunits, particularly of the eyebrow and forehead, are common in Mohs micrographic surgery. An important consideration when repairing these defects is maintaining continuity in the positioning and hair direction of the mid brow, which is crucial for facial cosmesis, and respecting the borders of adjacent cosmetic subunits.
Case Information: A 67-year-old male was referred for Mohs micrographic surgery of a biopsy-proven basal cell carcinoma on the right eyebrow with a pre-operative size of 1.6 x 1.2 cm. The tumor was cleared in two stages with a postoperative defect measuring 2.0 x 1.4 cm, involving and extending into the majority of the mid-eyebrow and the lower forehead.
Discussion/Clinical Findings: A multi-tier approach involving dual, opposing A-to-T flaps-collectively termed the "Cruciate Flap"-was used to recruit temporal laxity to close the defect under minimal tension and restore the position of the mid-brow. Bilateral relaxing incisions were made along the relaxed skin tension lines of the superior border of the brow, and a standing cone was excised from both the superior and inferior aspects of the defect, allowing for closure of the portions of the defect that extended into the forehead and mid-eyebrow, respectively.
Conclusion: A variety of reconstructive options were considered, but a local advancement flap from the ipsilateral side was deemed most suitable to (1) match hair color, density, and directionality of the recipient site; (2) maintain symmetry of the brow shape and height relative to the contralateral brow; (3) maintain the position of the medial brow, which is most significant to cosmesis; (4) allow horizontal incisions to be hidden along the hairline of the eyebrow.