I would ask the opinion of a plastic surgeon. As far as I know the most simple
method would be to apply a split skin graft. A superior cosmetic result may be
obtained with more elaborate reconstructions, however with increasing
complexity comes increasing risk. The main concern in this gentleman would be
to remove the lesion and secure rapid healing with a good oncologic result and
minimal risk.
Healing by secondary intention would occur but take a long time and cause the
patient ongoing discomfort and inconvenience. Even though purulant material
was coming from the lesion, there was no surrounding cellulitis so
reconstruction at the time of the excision is reasonable.
A full thickness or Wolff graft is useful in this location and gives a
superior cosmetic result to split skin, however the defect in this case is too
large for a full thickness graft and the chances of it taking would be low. In
addition, taking a large enough full thickness graft would leave another
defect that would require reconstruction.
A transverse rectus abdominus (TRAM) flap is a large flap that takes a skin
ellipse with underlying rectus sheath with the rectus abdominus muscle which
is divided low down to preserve the superior epigastric artery and vein which
supplies circulation to the flap. This flap is then rotated to fill another
defect most commonly to reconstruct the breast following mastectomy. It would
not reach the head and would be too bulky if it did.
A free flap could be taken from somewhere and the blood vessels anastamosed to
those in the defect in the temple, but this is too elaborate and risky an
operation in this elderly gentleman in whom a split skin graft would work well
with low risk.
