Large Frontal Defect Reconstructed with a Suprafascial Anterolateral Thigh Flap and Brow Suspension with a Fascia Lata Frontalis Sling

A 60-year-old gentleman presented with a single, dark scaly lesion over the forehead for the past 8 years. It started as a small plaque spontaneously, insidious in onset and gradually progressed to the present size. There was no history of trauma, pain or bleeding from the lesion. No history of similar complaints in the family. On examination, there was a large hyperpigmented plaque measuring 15 x 10 cm with well-defined margins and rolled-out edges with ulceration 2 x 0.5cm at the centre. (Fig. 1) Edge wedge biopsy from the lesion revealed a proliferation of basaloid cells which showed features consistent with basal cell carcinoma - atypical mitosis and peripheral palisading.  After obtaining anaesthetic fitness, we proceeded with wide local excision with 1cm margin done by the surgical oncology team. (Fig. 2) We then followed by reconstruction of the frontalis sling using fascia lata and covered the defect with a free suprafascial ALT flap with superficial temporal as the recipient artery as an end-to-end anastomosis. (Fig. 3, 4) The donor site was resurfaced with SSG. The histopathology report was consistent with basal cell carcinoma without any perineural involvement. The early postoperative period showed the flap supple and soft with no oedema. (Fig. 5) On regular follow-up, the flap was well settled with good cosmesis. (Fig. 6)