The Role of Tissue Expansion in theManagement of Large Congenital PigmentedNevi of the Forehead in the Pediatric PatientBruce S. Bauer, M.D., Julius W. Few, M.D., C. D. Chavez, M.D., and R. D. Galiano, B.A.Chicago and Maywood, Ill.

The authors present a cohort of 21 consecutive patientswho had congenital pigmented nevi covering 15 to 65percent of the forehead and adjacent scalp and who weretreated at their institution within the last 12 years. Allpatients were treated with an expansion of the adjacenttexture- and color-matched skin as the primary modalityof treatment. The median age at presentation was approx-imately 1 year; mean postoperative follow-up was 4 years.Nevi were classified according to the predominant ana-tomic areas they occupied (temporal, hemiforehead, andmidforehead/central); some of the lesions involved morethan one aesthetic subunit.

The authors propose the following guidelines: (1) Mid-forehead nevi are best treated using an expansion of bi-lateral normal forehead segments and advancement ofthe flaps medially, with scars placed along the brow andat or posterior to the hairline. (2) Hemiforehead nevioften require serial expansion of the uninvolved half ofthe forehead to minimize the need for a back-cut to re-lease the advancing flap. (3) Nevi of the supraorbital andtemporal forehead are preferentially treated with a trans-position of a portion of the expanded normal skin medialto the nevus. (4) When the temporal scalp is minimallyinvolved with nevus, the parietal scalp can be expandedand advanced to create the new hairline. When the tem-poroparietal scalp is also involved with nevus, a transpo-sition flap (actually a combined advancement and trans-position flap because the base of the pedicle movesforward as well) provides the optimal hair direction for thetemporal hairline and allows significantly greater move-ment of the expanded flap, thereby minimizing the needfor serial expansion. (5) Once the brow is significantlyelevated on either the ipsilateral or contralateral side fromthe reconstruction, it can only be returned to the preop-erative position with the interposition of additional, non–hair-bearing forehead skin. Expansion of the deficientarea alone will not reliably lower the brow once a skindeficiency exists. (6) In general, one should always use thelargest expander possible beneath the uninvolved fore-head skin, occasionally even carrying the expander underthe lesion. Expanders are often overexpanded. (Plast.Reconstr. Surg. 107: 668, 2001.)

Although the exact incidence and timing ofmalignant degeneration in large congenitalpigmented nevi remains a topic of controversy,there is little debate regarding the aestheticdeformity presented by large congenital pig-mented nevi in the facial area.1–4 Early excisionand reconstruction provide significant benefitsin both these areas of concern; however, theliterature has paid little attention to recon-struction of the forehead after nevus excisionin the pediatric population. Traditional meth-ods such as skin grafting, although providingacceptable coverage for forehead reconstruc-tion in the adult population, rarely result inoptimal results in children, even when the en-tire aesthetic unit of the forehead is grafted.5

Tissue expansion has given surgeons theability to harvest large flaps of color-, thick-ness-, and texture-matched skin while simulta-neously minimizing donor-site defects.6 Sinceits introduction, tissue expansion has beenused to solve a wide variety of reconstructiveproblems, with a significant increase in therefinement of its application.7–13 In this article,we describe the evolution of our techniques forthe excision and reconstruction of large andgiant congenital pigmented nevi of the fore-head and the positive effect specific modifica-tions in technique have had on the final aes-thetic outcome. Our current approach is basedon a review of a large series of patients inwhom tissue expansion provided the necessarytissue to reconstruct this challenging area. Thematerial presented is based on lessons learnedearly in this series and the changes in tech-

From the Division of Plastic Surgery, Children’s Memorial Hospital, Northwestern University Medical School, and the Department of Surgery,Loyola University Medical Center, Loyola Medical School. Received for publication October 13, 1999; revised June 5, 2000.

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nique that have allowed a more predictableoutcome.

PATIENTS AND METHODS

Patients

The patients presented in this review wereclassified as having large or giant congenitalnevi based on the amount of total body surfacearea involved and the inability to primarily ex-cise and close these lesions.14,15 We selected 21consecutive patients who had nevi covering 15to 65 percent of the forehead, with many hav-ing additional extension of the nevus into ei-ther the scalp or adjacent facial areas. Thispatient base was accumulated over a 12-yearperiod by the senior author and represents asubset of 220 patients with large or giant nevicovering 2 to 50 percent of the total bodysurface treated who were followed for the past20 years. Eighty of the patients in this largerseries had nevi involving the head and neck.The group reviewed in this article ranged inage from 6 months to 3.5 years at the time ofinitial presentation.

Surgical Technique

Rectangular expanders with remote fill portswere used in all patients. In the majority ofcases, 200- to 325-cc expanders were used. Ex-panders were filled with 100 to 550 cc of liquid.An average of 2.4 expanders was used per pa-tient, and patients averaged 1.5 courses of ex-pansion to complete the nevus expansion andreconstruction. The incisions were generallymade within the border of the nevus or poste-rior to nevi in the midforehead, and expanderswere placed in the subgaleal and subfrontalisplane. Then, 19-gauge butterfly drains wereplaced (one for each expander) in each pa-tient. The wounds were closed using 4-0 clearnylon sutures in the galea and dermis andrunning 4-0 nylon in the skin. At the comple-tion of the procedure, the expanders were in-jected to a comfortable intraoperative fill toensure a smooth contour to the expander sur-face and to minimize dead space within thepocket.

Typically, sutures were left in place through-out the expansion period unless there was anunusual amount of perisuture inflammation.Weekly injections began 7 to 10 days postoper-atively and continued for a total of 5 to 12weeks. Initially, most of the flaps were of arotation/advancement design, but with in-

creasing experience, transposition flaps offorehead skin were used for the lateral fore-head, and temporal area and occipital transpo-sition flaps were used for reconstruction of thetemporoparietal scalp and temporal hairline.

Patients with large or giant nevi extendinginto the periorbital area, eyelids, and nasalarea were treated with either expanded or non-expanded full-thickness skin grafts. The graftswere typically staged after most of the foreheadhad been reconstructed.

RESULTS

Follow-up for these patients ranged from aminimum of 2 to 9 years. All forehead recon-structions after tissue expansion were consid-ered successful in that in each case, the nevuswas completely excised and replaced with nor-mal adjacent skin (Figs. 1 through 3). Theaesthetic outcome was critically assessed bylooking at symmetry, hairline/brow position,hair root direction, and scar appearance. Mi-nor aesthetic abnormalities that were nottreated surgically were still considered minorcomplications. The majority of the expandedflap procedures in the early half of the seriesconsisted of advancement flaps; the latter halfconsisted of transposition flaps, particularly fortemporal and hairline reconstruction (Table I).

Complications and Treatment

Two patients were excluded from the study.One patient had an initial nevus excision andreconstruction with a Washio flap that pre-dated the senior author’s initial treatment. An-other patient had other craniofacial anomaliesthat complicated management and outcomeassessment. Complications were divided intothose typical for tissue expansion in generaland those unique to the forehead area.

In this study, two patients (9 percent) expe-rienced typical expander complications of in-fection and exposure. The patient with an earlyinfection had the expander removed and, sub-sequently, underwent uncomplicated recon-struction. The exposure in the second patienthad no negative effect on the plannedreconstruction.

Five patients (24 percent) had complicationsunique to the expansion of the forehead re-gion, particularly brow elevation, brow ptosis,abnormal hair direction, or anterior hairlineasymmetry. The rate of these minor aestheticcomplications decreased from 29 percent to 14percent when comparing the early half to the

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FIG. 1. Midforehead and bilateral supraorbital forehead nevus. (Above, left) This7-month-old child presented with a deeply pigmented congenital nevus coveringapproximately 65 percent of her forehead. Early biopsy demonstrated the extension

670 PLASTIC AND RECONSTRUCTIVE SURGERY, March 2001

later half of the series. In the case of browasymmetry, correction was delayed for at least12 months after reconstruction to optimizescar maturation, allow natural relaxation of thesurrounding tissue, and allow remodeling ofany postexpansion cranial molding.

Subsequent procedures were performed,when necessary, to reestablish brow symmetry;all proved successful. These procedures in-cluded Z-plasty transposition of the elevatedcontralateral brow (Fig. 4) and, more com-monly, crescent excision of skin above thebrow to elevate a ptotic ipsilateral brow.

DISCUSSION

Tissue expansion is widely accepted as aninvaluable adjunct for the reconstruction ofthe head and neck in adults and chil-dren.13,16–21 Reconstruction of the forehead inchildren presents distinctive challenges in ad-dition to the ones typically seen in the adultpopulation. Traditional methods such as skingrafting, although providing acceptable cover-age for forehead reconstruction in the adultpopulation, rarely result in optimal results inchildren, even when the entire aesthetic unit ofthe forehead is grafted.5 Thus, tissue expansionand flap design must be optimized to ensurethat the landmarks of the forehead aestheticunit will be disturbed as little as possible. Par-ticular emphasis is placed on brow symmetry,temporal hairline position and hair direction,and scar orientation. This article is meant toprovide a supplement to the existing literature,underscoring the importance of aesthetic con-siderations20,22–24 and outlining a systematic wayof planning expander placement and flap de-sign to minimize the distortion of the anatomiclandmarks.

Although reconstruction of the entire fore-head aesthetic unit may not be possible with-out a single sheet graft or distant flap whendealing with a large nevus of the central fore-head, tissue expansion allows for donor tissueto be confined to the forehead aesthetic unit,

without disrupting the periorbital, cheek, ormidface. If the surrounding landmarks of browand hairline are preserved or reconstructedsymmetrically, then the central midline scarcan still provide an acceptable outcome. Dis-tortions of hairline and brow position tend tobe more common when dealing with lesions ofthe hemiforehead, lateral forehead, and tem-poral region, and it is in these areas that mod-ifications of the traditional advancement flapdesign are most important.

To our knowledge, this study represents thelargest series with long-term follow-up thatdemonstrates a reliable approach to the treat-ment of forehead giant nevi. The goal of com-plete nevus excision while maintaining the an-atomic relationship of the brow, hairline, andhair pattern was achieved in all patients. Withthe critical analysis of our earlier work, we havefound some useful guidelines, which help sim-plify the preoperative plan and allow for morepredictable results.

Guidelines

Midforehead nevi are best treated with theexpansion of bilateral normal forehead seg-ments and advancement of the flaps medially,with scars placed along the brow and at orposterior to the hairline.

Hemiforehead nevi often require serial ex-pansion of the uninvolved half of the foreheadto minimize the need for a back-cut to releasethe advancing flap. Repeated expansion willalso minimize the likelihood of contralateralbrow distortion by focusing the area of secondexpansion closer to the site of remaining nevusin the temporal region.

Nevi of the supraorbital and temporal fore-head are preferentially treated with a transpo-sition of a portion of the expanded normalskin medial to the nevus. The transposed flapprovides a pennant of tissue between the lat-eral brow and hairline, places the scars alongthe brow, and relaxes the skin tension lines on

of the nevus into the frontalis muscle. The two 100-cc expanders were placed through an incision down the midline of the nevus.(Above, right) One of the two rectangular remote port expanders before placement. (Center) The child returned for nevus excisionafter 8 weeks of expansion. The nevus was completely excised except for a small strip in the midforehead and at the glabella.(Below, left) The results at 3 months after excision showing the hairline, brow position, and maintenance of non–hair-bearingtemporal skin lateral to the brow. (Below, right) The result at 5 years after the initial excision and reconstruction and 4 years afterthe excision of the nevus that remained in the forehead and glabella and revision of the scars along the left medial brow.Reproduced with permission from Vistnes, L. (Ed.). Procedures in Plastic and Reconstructive Surgery: How They Do It. Boston: Little,Brown, 1991. P. 304.

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the forehead and along the temporal hairline,thus avoiding the brow and hairline distortionoften created by a direct advancement flap.

When the temporal scalp is minimally in-

volved with nevus, the parietal scalp can beexpanded and advanced to create the new hair-line. When the temporoparietal scalp is alsoinvolved with nevus, a transposition flap (actu-

FIG. 2. Hemiforehead nevus. (Above, left) This 8-month-old child presented with an 8 3 9 cm congenital nevus of the lefthemiforehead and scalp. The nevus did not extend down to the brow. Initial expander placement was complicated by earlyinfection, and the expanders were removed within the first 10 days and before significant expansion could proceed. Twoexpanders were then placed (200 cc in forehead and 325 cc in scalp). The anterior expander was positioned beneath the nevusand uninvolved skin above the brow with a plan to advance this skin to the hairline, if possible. The second expander was placedposterior to the nevus to transpose a flap forward to reconstruct the hairline. (Above, center) Forehead expander at 240 cc and(above, right) posterior scalp expander at 345 cc before nevus excision. (Below, left) Positioning of the remote injection ports.(Below, center) Result at 4 months after excision/reconstruction shows placement of scar in relaxed skin tension lines and alonghairline. The brow was left slightly ptotic medially at the point of the “dog-ear” to minimize overall scar length. The fullness abovethe brow represents residual swelling. (Below, right) The final result 1 year after scar revision, excision of the dog-ear, and finalbrow positioning, which was performed 15 months after the first excision.

672 PLASTIC AND RECONSTRUCTIVE SURGERY, March 2001

ally a combined advancement and transposi-tion flap because the base of the pedicle movesforward as well) provides the optimal hair di-rection for the temporal hairline and allowssignificantly greater movement of the ex-panded flap, thereby minimizing the need forserial expansion.

Once the brow is significantly elevated oneither the ipsilateral or contralateral side fromthe reconstruction, it can only be returned tothe preoperative position with the interposi-tion of additional non–hair-bearing foreheadskin. Expansion of the deficient area alone willnot reliably lower the brow once a skin defi-

ciency exists. Thus, one should err toward mak-ing the brow ptotic when exact brow symmetrycannot be ensured. The ptosis often resolveswith time or is easily corrected with a minorexcision of excess skin above the brow or en-doscopically assisted brow suspension.

In general, one should always use the largestexpander possible beneath the uninvolvedforehead skin and occasionally even carry theexpander under the lesion. Expanders are typ-ically overexpanded as well.

Using these standard principles, with repro-ducible flap design and expander placement,these challenging lesions have been managed

FIG. 3. Temporal nevus. This 6-month-old child presented with a 9 3 7 cm congenital pigmented nevus of the left temporalarea with extension into the parietal scalp. Photographs above, left and above, center show the nevus in the anteroposterior andlateral views, respectively, before placement of expanders. (Above, right) The child is shown with a 100-cc subfrontalis expanderanteriorly and a 200-cc expander in the parietooccipital area shortly before nevus excision. The nevus was excised after 8 weeks ofexpansion, and the reconstruction was performed with a rotation-advancement of the expanded forehead skin into the temporal regionand a transposition flap of the occipital scalp to reconstruct the temporal hairline. (Below, left) Result at 4 months postoperativelydemonstrates the hairline reconstruction and completion of the aesthetic unit of the forehead. (Below, right) The result at 10 monthspostoperatively shows maintenance of symmetrical brow position and restoration of normal temporal landmarks.

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with a lower overall major complication rate (9percent) and acceptable aesthetic results. Inaddition, less than half of the minor aestheticcomplications required a surgical revision. Ourresults compare favorably with other smallerseries.19,20 Once the principles outlined abovewere applied in this series, we had fewer aes-thetic complications. Although there are sev-eral options in the treatment of large/giantnevi, including simple excision and skin graft-

ing, we think that the use of expanded localflaps provide the best aesthetic reconstruction.A careful plan, with the understanding of thepotential pitfalls unique to the forehead, canprovide reproducible and dependable resultswhile minimizing complications.

Bruce S. Bauer, M.D.Division of Plastic Surgery2300 Children’s Plaza, Box #41Chicago, Ill. 60614

FIG. 4. Treatment of aesthetic complication. (Above, left) This girl had a leftsupraorbital/temporal nevus and was treated in the first part of the series with singleexpansion of the uninvolved forehead and advancement along the brow and back-cut above the lateral contralateral brow. (Below) Note the postoperative contralateralbrow elevation due to excessive back-cutting. (Above, right) View after treatment ofright brow elevation with Z-plasty transposition of the stretched lateral supraorbitalskin to restore brow symmetry.

TABLE IPatient Summary

Location of NeviNo. of

PatientsMean Age

(mo)Mean No. ofExpanders

Rounds ofExpansion

Mean ExpansionTime (wk)

Complications/Corrections

Major Minor

Midforehead 3 6.3 2 1 5.6 NA 0Hemiforehead 3 7 3 2 8 Infection (1) 1Supraorbital and temporal 6 8 2.5 1.5 8.4 Exposure (1) 1Temporal 6 7.5 2 1.5 7.8 NA 2Hemifacial 3 5.6 4 2 6 NA 1Summary 21 7 2.4 1.5 7.4 2 5

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