Refinements of tissue expansion for pediatric forehead reconstruction: a 13-year experience.

BACKGROUND: Reconstruction of the forehead in children when 25 percent or more of the forehead is involved presents a complex reconstructive challenge because of the confluence of highly visible aesthetic units. The present study was performed to develop an algorithm for lesions involving 25 percent or more of the forehead.
METHODS: A 13-year retrospective review was performed of all pediatric patients who completed reconstruction for lesions involving at least 25 percent of the forehead by a single surgeon (A.K.G.). All lesions were classified on the basis of percentage of forehead involved and involvement of adjacent subunits.
RESULTS: Twenty patients completed reconstruction. The median number of surgical procedures required was six (range, two to 11), with a median of three (range, one to four) expansion procedures. Simultaneous expanders were placed in the scalp (16 patients) and cheek (eight patients). Five patients underwent correction of eyebrow ptosis at a final procedure. Reconstruction involved 25 to 70 percent of the forehead in 19 patients, 17 of whom were reconstructed with serial forehead expansion and advancement flaps. One patient with a pigmented nevus occupying more than 75 percent of the forehead received an expanded full-thickness skin graft from the lower abdomen. For all groups, the entire extent of the visible lesion was excised and complete skin coverage achieved.
CONCLUSIONS: Reconstruction of 25 to 70 percent or more of the forehead in children is best accomplished using tissue expansion and direct advancement of adjacent tissues. Simultaneous expansion should be performed in the cheek and scalp if indicated. Brow ptosis should be addressed with each advancement. Lesions greater than 70 percent of the forehead are best accomplished with distant tissues.