Forehead Pressure Necrosis following Circumferential Head Dressing: Small Case Series and Comprehensive Review of Literature

Purpose: we aimed to report 4 patients (from 4 different surgeons) with forehead and eyebrow PUs after endoscopic forehead lift (3 patients) and dermoid excision (1 patient) as well as review the literature to recommend a stepwise approach to forehead PU. Methods: Literature review was performed (January 2019) using the Medline database on Pubmed with the following search terms: pressure injury, pressure ulcer, pressure necrosis, pressure sore, facial pressure injury, pressure dressing injury, circumferential dressing injury, circumferential bandage injury, and device necrosis. After reviewing the articles, total number of 96 articles were finally included. Results: PU developed in otherwise healthy subjects after endoscopic forehead lifting (3 patients) and dermoid excision (1 patient) with encircling head dressing (16- 72 hours). It gradually improved wiyh almost no visible scar in one subject and visible scar in 3 subjects at the last follow up. PU occurs in systemically ill patients with:immobility with fixed prolonged position, diabetes, perfusion impairment, and use of medical devices. Head and neck is the most frequent site in device-related PU. External pressure, shearing forces, and reperfusion injury are 3 main contributing factors in its pathophysiology. Prevention is based on management of the underlying diseases, external pressure release, and frequent skin examination. Treatment strategy is according to the stage of PU and presence of concomitant infection which include wound dressing and debridement as well as using antiseptics, antibiotics, and nutrients. Conclusion: Early loosening of the encircling head dressing and frequent examination of the skin are the only preventive and diagnostic measures. Immediate removal of the pressure and staging of PU are the starting treatment actions. While different wound dressings have been proposed, none has shown a superiority over the others. Wound debridement is an essential step for granulation and epithelialization. Good hydration, sufficient calorie intake, and vitamin/ mineral supplements help heal the PU.