Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Single Port Endoscope-Assisted Excision of Forehead Lesions: An Innovative Way of Improving the Optical Cavity Vairavan Narayanan, FRCS,  Ronie Romelean Jayapalan, MRCS,  Amritpal Singh Sidhu, FRCS,  and Kiok Miang Roy Koh, FRCS y Abstract: Exophytic lesions involving the face present with an undesirable esthetic deformity and usually necessitate surgical excision. Conventional open excision techniques may lead to scar formation or pigmentation issues postoperatively. Minimally inva- sive endoscope-assisted surgery will be able to overcome these problems. However, this technique is not widely used because of the limited optical cavity working space, which hinders good visuali- zation. We describe a technique to improve the optical cavity workspace to enable adequate endoscope-assisted surgical excision of forehead lesions in 2 cases. Foley’s catheter and ribbon gauze were used in both cases to gain optical cavity workspace. The surgical technique is described in detail. One case had a frontal osteoma, whereas other was a nodular fasciitis of the forehead, confirmed by histology. Postoperative follow-up showed good outcomes at 1 year with no recurrences. Both patients were satisfied with the surgical and cosmetic outcomes. Endoscopic excision of a forehead lesion using the described technique is both safe and reliable. It is an excellent method for excising benign growths over the forehead while being cosmetically acceptable. Key Words: Benign, endoscope, forehead, optical cavity, single port (J Craniofac Surg 2019;30: 841–842) E xophytic lesions involving the face usually present with an undesirable aesthetic deformity. Excision of these lesions is usually necessitated for cosmetic purposes. However, the conven- tional technique of open excision may lead to scar formation or scar-related pigmentations over the operative site, especially in the forehead area. This may defeat the purpose of a cosmetic procedure. Multiple techniques of endoscope-assisted excision of forehead lesions have been described and have evolved over time, ranging from a 3- or 2-port technique and recently a single-port technique. However, this technique has not picked up traction because of the limited optical cavity working space, which hinders good visualization. In this article, we describe 2 cases in which a minimally invasive single-port technique was utilized in the excision of the forehead lesions, with the assistance of a Foley’s catheter and ribbon gauze to create the optical cavity of the workspace. METHODS We describe 2 patients who presented with forehead lesions over the mid-frontal region. Both were female patients, aged 14 and 36 years, respectively. The first patient had a progressively enlarging lesion along the right superior temporal line of the mid-forehead, measur- ing 9 mm in diameter. The second patient had a progressively enlarging bony lesion 2 cm superior to the supraorbital notch, measuring about 1.2 cm in diameter. Clinical examination and imaging were suggestive of an exophytic soft tissue lesion below the subcutaneous tissue for the first case, whereas the second case was consistent with a frontal osteoma. Both the lesions were firmly adherent to the underlying bone. The procedure utilized a 30-degree Karl Storz 4.5-mm endo- scope, periosteal elevator, Midas Rex Legend high-speed drill, Legend Ball or Match Head-Fluted 2.0 mm burr, ribbon gauze, and Foley catheter. A high-definition (HD) endoscope monitor was used for visualization. OPERATIVE PROCEDURE Both surgeries were performed under general anesthesia. The lesion was marked out preoperatively. A linear 1.5-cm incision was marked 2 cm posterior to the hairline (Fig. 1A). The hair along the incision was clipped, cleaned, and draped in a sterile manner. Local anesthesia (Marcaine 0.5%-adrenaline) was infiltrated along the incision. A size 11 blade was used to make the incision deep to the galea aponeurotica. A periosteal elevator was used to elevate the subperiosteal layer through a relatively bloodless plane toward the marked lesion. Once the periosteum was elevated, 2 size 16 Foley catheters were inserted and inflated with air within the subperiosteal plane to create the initial cavity (Fig. 1B). An endoscope was introduced into the space created to visualize the target lesion (Fig. 1C). To keep the optical cavity open without overzealous retraction, ribbon gauze was packed on either side of the lump (Fig. 1D). The Foley catheter was then removed. This maneuver provided the much-needed working space to excise the lesion by holding up the overlying scalp (Supplemental Video, Supplemental Digital Content, http:// links.lww.com/SCS/A404). From the  Department of Surgery, Division of Neurosurgery, University Malaya Medical Centre, Malaysia; and y FeM Surgery, Mount Elizabeth Medical Centre, Singapore. Received August 28, 2018. Accepted for publication November 11, 2018. Address correspondence and reprint requests to Vairavan Narayanan, FRCS, Department of Surgery, Division of Neurosurgery, University Malaya Medical Centre, Lembah Pantai, 59100 Kuala Lumpur, Wilayah Persekutuan, Malaysia; E-mail: nvairavan@um.edu.my Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jcraniofa- cialsurgery.com). The authors report no conflicts of interest. Copyright # 2019 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000005185 CLINICAL STUDY The Journal of Craniofacial Surgery  Volume 30, Number 3, May 2019 841