Forehead, Eyelid, and Lip Scar Reconstruction

Special Topics

The forehead, eyelids, and lips are important areas of the face. When scars appear in these places, even mild scarring, depression, pulling, or color difference can be easy for others to notice.

These areas also have clear functions: the forehead affects eyebrow position and the hairline, the eyelids are responsible for opening and closing the eyes and protecting the eyeball, and the lips are essential for eating, speaking, facial expression, the shape of the mouth corners, and continuity of the vermilion border.

For this reason, scar reconstruction in these areas is not only about repairing the scar itself. It also aims, as much as possible, to restore contour, movement, symmetry, and skin texture.

Forehead Scar Reconstruction: Protecting the Eyebrows, Hairline, and Skin Texture

Forehead scars often occur after burns, trauma, surgical incisions, or removal of skin lesions.

A plastic surgeon needs to assess several factors, including the size and location of the scar, whether it pulls on the eyebrow, whether it affects forehead expression, and whether the surrounding skin is loose enough.

Small linear scars may be treated with precise excision, layered tension-reducing sutures, Z-plasty, or W-plasty, with the goal of making the scar direction follow the natural skin lines. After excision of a larger scar, direct closure may shift the eyebrow, distort the forehead, or create excessive incision tension; in that situation, a flap or tissue expansion may need to be considered.

An expanded scalp flap is a commonly used method for reconstruction of forehead and some facial lesions. The treatment process involves choosing an expander according to the lesion size, placing it beneath the galea aponeurotica, and, after sufficient expansion, using direct advancement or a transposition flap to repair the wound after excision.

Forehead reconstruction also needs to account for hair. Scalp flaps have a rich blood supply and provide enough tissue volume, but after transfer to the forehead or face they may carry hair, so several sessions of postoperative laser hair removal are often needed.

Eyelid Scar Reconstruction: Restore Eye Closure and Eyeball Protection First

The functional requirements for eyelid scars are very high. For example, the upper eyelid must be able to lift and close, the lower eyelid must fit against the eyeball, and the positions of the medial and lateral canthi must remain stable.

Scar contracture can cause ectropion, entropion, incomplete eyelid closure, tearing, dry eye, and corneal irritation; in severe cases, it can affect vision.

For post-traumatic eyelid deformities, such as common lower eyelid ectropion, medial canthal scar contracture, displacement of the medial canthal ligament, and displacement of the lateral canthal point, doctors often use double-eyelid incision approaches, modified Z-flap medial canthoplasty incisions, and lateral canthoplasty incisions, combined with full-thickness skin grafting, medial canthal ligament anchoring, and lateral canthal ligament suspension for repair.

Eyelid ectropion is usually caused by scar contracture or a defect of the skin and soft tissue. Treatment requires complete release of the scar contracture, followed by use of a full-thickness skin graft, expanded flap, myocutaneous flap, or free flap according to the defect.

Why should eyelid surgical incisions be hidden as much as possible?

Eyelid skin is very thin, and the local anatomy is complex, so the incision position directly affects the postoperative appearance. The double-eyelid crease, medial canthal fold, and natural lateral canthal lines are all concealed incision areas that can be used. By entering the operative field through these cosmetic incisions, doctors can release the scar, graft skin, reposition the canthal ligaments, and reconstruct eyelid shape at the same time, reducing the need for additional incisions.

Lip Scar Reconstruction: Aligning the Vermilion Border, Mouth Corners, and Facial Expression

Lip scars are commonly seen after burns, scalds, trauma, tumor removal, infection, or surgery.

The upper lip is especially sensitive because it includes the vermilion border, philtral ridges, philtral dimple, nasolabial fold, mouth corner, and mustache area. Even slight misalignment can cause obvious asymmetry. When doctors assess lip scars, they focus on whether the vermilion border is continuous, whether the mouth corner is being pulled, whether mouth opening is restricted, whether the nasolabial fold has disappeared, and whether the skin color and thickness match.

For repair of skin and soft-tissue defects of the upper lip, one available method is a nasolabial cheek flap. Its advantages are that it is adjacent to the defect, similar in color and texture, and the incision can be partly hidden near the nasolabial fold, making it suitable for small to medium defects of the upper lip. For larger scars around the mouth and chin, when local skin is insufficient, an expanded flap or pedicled flap may be considered.

Scars around the mouth, chin, and cervicofacial region should also be assessed for functional pulling.

If scars around the mouth and chin are large, they may pull on the lower lip, mouth corner, nasal ala, and chin-neck region. Patients may develop restricted mouth opening, drooling, lower-lip eversion, unclear speech, and unnatural facial expression. Cervicofacial scars may also affect looking down, looking up, and turning the head.

At this stage, the treatment goal is therefore not limited to improving the skin surface. It must also consider release of deep scar adhesions and restoration of the anatomical positions of the mouth, nose, chin, and neck.

How Doctors Choose the Reconstruction Method

Small, superficial linear scars are often treated with precise excision, tension-reducing sutures, Z-plasty, or W-plasty. When local tissue is insufficient but the nearby skin is in good condition, a local flap can be used. When the area is larger, color and texture matching requirements are high, and expandable surrounding skin is available, tissue expansion can be considered.

For repair of larger forehead and facial lesions, scalp flaps or expanded scalp flaps can provide a larger amount of tissue. Eyelid scar deformities must be designed separately according to findings such as ectropion, entropion, conjunctival sac defect, and displacement of the canthal ligaments.

In addition, the treatment plan also depends on the patient's age, whether the scar is stable, whether there is a tendency toward keloid formation, local blood supply, previous surgical history, and ability to manage postoperative care.

For delicate areas such as the eyelids and lips, doctors generally prefer adjacent tissue with similar color, thickness, and texture, which helps reduce obvious color mismatch and secondary deformity.

Postoperative Care Also Affects the Final Result

After reconstruction of forehead, eyelid, and lip scars, new incisions will still be present. Postoperative care therefore needs to control tension, prevent infection, monitor flap blood flow, remove sutures on schedule, use silicone or tension-reducing products, and add laser, injection, or pressure therapy according to the situation.

After surgery around the mouth, oral hygiene is important, and excessive mouth opening that pulls on the incision should be avoided. After eyelid surgery, eye closure, corneal irritation, tearing, and eyelid-globe apposition should be monitored. After forehead and scalp flap surgery, attention should be paid to the hairline, eyebrow position, and hair-removal areas.

For expanded flaps, the expansion period itself requires management. Overly rapid saline injection, poor flap blood flow, infection, and expander exposure can all affect later surgery.

How Much Improvement Can Be Achieved After Repair?

When conditions are suitable, linear forehead scars, small eyelid scars, and localized upper-lip defects can become noticeably thinner, flatter, and lighter after careful design, and may even be difficult to notice at normal social distance.

The goals for complex scars are broader, including restoring eyelid closure, improving ectropion or entropion, correcting pulling of the mouth corner and nasal ala, restoring eyebrow position, and reducing color difference and contracture.

Scar reconstruction cannot guarantee complete restoration to pre-injury skin, but through precise incision design, adjacent tissue flaps, expanded flaps, full-thickness skin grafts, canthal ligament fixation, laser hair removal, and postoperative anti-scar management, appearance and function can be improved to a more stable state.