Descending the reconstructive ladder: Salvage reconstruction by tissue expansion to revise a free flap-based forehead reconstruction

Forehead defects pose a reconstructive challenge and multiple revisions are often required to achieve satisfactory outcomes. The case history of a 20-year-old woman undergoing radical resection of a forehead arteriovenous malformation and reconstruction with an anterolateral (ALT) free flap is described. Although free tissue transfer with an ALT was successful, its color and texture mismatch were unacceptable to the patient. The esthetic result and patient satisfaction were improved by subsequent tissue expansion of the contralateral forehead, removal of the free flap and advancement of the contralateral forehead skin. Complex reconstructions utilize a breadth of techniques. We illustrate a dynamic use of the reconstructive ladder, implementing a descending approach to achieve a satisfactory reconstruction objectively and subjectively from the patient perspective.