The role of tissue expansion in the management of large congenital pigmented nevi of the forehead in the pediatric patient

The authors present a cohort of 21 consecutive patients who had congenital pigmented nevi covering 15 to 65 percent of the forehead and adjacent scalp and who were treated at their institution with the last 12 years. All pati ents were treated with an expansion of the adjacent texture- and color-matc hed skin as the primary modality of treatment. The median age at presentati on was approximately 1 year; man postoperative follow-up was 4 years. Nevi were classified according to the predominant anatomic areas they occupied ( temporal, hemiforehead, and midforehead/central): some of the lesions invol ved more than one aesthetic subunit. The authors propose the following guidelines: (1) Midforehead nevi are best treated using an expansion of bilateral normal forehead segments and advan cement of the flaps medially, with scars placed along the brow and at or po sterior to the hairline. (2) Hemiforehead nevi of ten require serial expans ion of the uninvolved half of the forehead to minimize the need for a back- cut to release the advancing flap. (3) Nevi of the supraorbital and tempora l forehead are preferentially treated wit a transposition of a portion of t he expanded normal skin medial to the nevus. (4) When the temporal scalp is minimally involved with nevus, the parietal scalp can be expanded and adva nced to create the new hairline. When the temporoparietal scalp is also inv olved with nevus, a transposition flap (actually a combined advancement and transposition flap because the base of the pedicle moves forward as well) provides the optimal hair direction for the temporal hairline and allows si gnificantly greater movement of the expanded flap, thereby minimizing the n eed for serial expansion. (5) Once the brow is significantly elevated on ei ther the ipsilateral or contralateral side from the reconstruction, it can only be returned to the preoperative position with the interposition of add itional, non-hair-bearing forehead skin. Expansion of the deficient area al one will not reliably lower the brow once a skin deficiency exists. (6) In general, on should always use the largest expander possible beneath the uni nvolved forehead skin, occasionally even carrying the expander under the le sion. Expanders are often overexpanded.