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Original Investigation |

Endoscopic Forehead Approach for Minimally Invasive Benign Tumor Excisions ONLINE FIRST

Haneen Sadick, MD1; Michael Huber, MD2; Stephen W. Perkins, MD3; Heather H. Waters, MD3; Grant S. Hamilton III4; Ashley G. O’Reilly4; Holger G. Gassner, MD2
[+] Author Affiliations
1Division of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology, University Hospital of Mannheim, Mannheim, Germany
2Division of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology, University Hospital of Regensburg, Regensburg, Germany
3Meridian Plastic Surgery Center, Indianapolis, Indiana
4Division of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
JAMA Facial Plast Surg. Published online June 19, 2014. doi:10.1001/jamafacial.2014.269
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Importance  Direct transcutaneous resection has been a widely accepted standard for the 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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Figure 1.
Equipment

Shown is standard equipment for the endoscopic forehead approach.

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Figure 2.
Endoscopic Forehead Approach for Benign Tumor Resection

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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Figure 3.
Location of the Forehead Lesions

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).

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Figure 4.
Endoscopic Resection of a Forehead Lipoma

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.

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Figure 5.
Two Representative Patients

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.

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