Forehead reconstruction secondary to giant congenital nevus, hemangioma and complex scar revision, requires a complex algorithm for tissue expansion in the pediatric population. We describe refinements in traditional approaches to this problem.

Ten-year retrospective review of 24 patients who underwent tissue expansion for forehead reconstruction. Parameters reviewed: eyebrow ptosis, hairline symmetry, placement of final scars, and aesthetic outcome.

When lesions involved 25 to 70% of the forehead (n=22) we used delayed expanded forehead rotation flaps (n=1), and serial expansion of forehead advancement flaps (n=20) for reconstruction. Serial excision was reserved for residual hyperpigmentation (n=9). Two patients whose lesion involved 70% of the forehead required an expanded skin graft. In patients reconstructed with expanded forehead flaps, the median number of expansion procedures required for completion was 3 (range: 1 to 5), and the median number of surgical procedures was 6.5 (range: 2 to 11). Simultaneous scalp tissue expanders were placed in 18 of 22 patients; simultaneous cheek tissue expanders were placed in 8 patients.

A combined modality surgical approach is necessary for optimal forehead reconstruction. Regardless of the reconstructive technique utilized, the forehead should be reconstructed as one aesthetic unit, confining scars to the hairline, upper brow, peri-auricular regions and temple.