Pediatric Dermatology Vol. 29 No.

5 621–624, 2012

Treatment of a Congenital Melanocytic Nevus

on the Forehead with Immediate Tissue
Expansion Technique: A Three-Year Follow-Up
M. Erol Demirseren, M.D.,* Candemir Ceran, M.D.,* and D. Deniz Demirseren, M.D., 
Departments of *Plastic Reconstructive and Aesthetic Surgery and  Dermatology, Ataturk Training and Research
Hospital, Ankara, Turkey

Abstract: The aim of this case report was to determine the method and
basic principles of immediate tissue expansion using a Foley catheter in the
forehead region for treating a medium-sized congenital melanocytic nevus.
A 4-year-old child presented with a supraorbitally located forehead congenital
melanocytic nevus, close to the midline. Total excision and reconstruction
with intraoperatively expanded forehead skin below the hairline was per-
formed. Intraoperative tissue expansion using a Foley catheter allowed us to
obtain expanded and enhanced local tissue, which had tissue characteristics
similar to those of the forehead skin, and thus closure of a medium-sized
defect without distorting important anatomic structures such as the brow
and frontal hairline was possible. Of the two methods of tissue expansion,
immediate expansion using a Foley catheter is a good alternative in single-
stage reconstruction of head and neck defects because it has the advantage
of omnidirectional expansion.

We present an immediate tissue expansion technique
using a Foley catheter as an inflatable expander for
single-stage reconstruction of a forehead congenital
melanocytic nevus in a 4-year-old child.
Tissue expansion is a relatively new method of
reconstruction and has the advantage of using the adja-
cent tissue while minimizing donor site morbidity. There
are two kinds of expansion; acute, intraoperative and
chronic, long term. The intraoperative immediate
expansion technique is more suitable for small or med-
ium-sized defects, whereas chronic, long-term expansion
is for larger defects (1).
Intraoperative tissue expansion with a Foley catheter
provides omnidirectional expansion, allowing us to
obtain expanded and enhanced local tissue, which has
characteristics similar to those of the forehead skin, and
thus closure of a medium-sized defect becomes possible
without distorting important anatomic structures such as
the brow and frontal hairline.
CASE REPORT
A 4-year-old child presented with a pigmented lesion on
the forehead. This lesion was first noticed at birth and
had grown and gradually become darker in color as the
child grew. Physical examination revealed a diamond-
shaped, 2- · 3-cm, dark-brown lesion located on the
right supraorbital area close to the midline. The lesion,

Address correspondence to M. Erol Demirseren, M.D.,

Konutkent-2 Sitesi B6-C Blok No: 4, 06810, Cayyolu, Ankara,
Turkey, or e-mail: medemirseren@yahoo.com.

DOI: 10.1111/j.1525-1470.2011.01554.x

 2012 Wiley Periodicals, Inc. 621

622 Pediatric Dermatology Vol. 29 No. 5 September ⁄ October 2012

Figure 1. A 4-year-old child with a congenital melanocytic Figure 2. A Foley catheter was inserted from the medial
nevus on the right supraorbital area close to the midline. incision, and the tip of catheter was extracted from the lateral
incision.

which was diagnosed clinically as a congenital melano-

cytic nevus, was 2 cm above the right brow and 3 cm
below the frontal hairline (Fig. 1).
The parents had been to another plastic surgery
clinic and were referred to surgery with the suggestion
of total excision and skin grafting. They were sensitive
regarding the aesthetic considerations and requested a
single-stage operation with a minimal final scar and no
additional scar on any other part of the body. After
evaluation and consultation with the parents, we deci-
ded to perform intraoperative tissue expansion and
primary closure of the defect. The forehead skin be-
tween the lesion and the frontal hairline was chosen as
the site for expansion. A Foley catheter (20Fr) was used
as an expander.
The patient was operated on under general anesthesia. Figure 3. The catheter was inflated with saline until the
One-centimeter-long incisions were made at both upper overlying skin became blanched.
lateral sides of the lesion, and the forehead skin below the
hairline was elevated using blunt dissectors. The dissec- boundaries of normal forehead skin to obtain the ex-
tion plane was the loose areolar tissue just above the panded skin only from the forehead region. The pocket
periosteum. The dissected pocket was kept in the was also kept small to avoid free movement of the Foley

Figure 4. Expansion cycles.


Figure 5. Defect after resection of the lesion.
Figure 6. Early postoperative result.
catheter. The catheter was inserted from the medial
incision, and the tip of catheter was extracted from the
lateral incision. The reservoir of the catheter was kept in
the dissected pocket (Fig. 2). The catheter was inflated
with saline until the overlying skin became blanched.
Care was taken not to exceed the maximum reservoir
volume (50 mL) limit of the catheter. The initial volume
was 35 mL. The duration of the first expansion period
was 7 minutes. After this expansion period, the pressure
was relieved for a 3-minute resting period. This 10-min-
ute period of expansion and resting was repeated four
times (Fig. 3). In subsequent cycles, expansion volumes
were increased 5 mL each (Fig. 4).
After the expansion was completed, the reservoir of
the Foley catheter was deflated, and the catheter was
extracted. Total excision of the lesion was performed
(Fig. 5). The initial incisions were added to the incision
for removal of the lesion. Primary closure of the defect
was achieved. Histopathologic examination revealed a
congenital melanocytic nevus.
No early postoperative complications such as hema-
toma or seroma formation, infection, or suture dehis-
Demirseren et al: Immediate Tissue Expansion 623
Figure 7. Late postoperative result.
cence were observed (Fig. 6). The slight elevation of the
right brow decreased gradually over time. The final
appearance of the surgical site at 3-year follow-up was
aesthetically satisfactory (Fig. 7).
DISCUSSION
The major concerns about congenital melanocytic nevi
are risk of malignant transformation and aesthetic con-
siderations. The exact incidence and timing of malignant
transformation in melanocytic nevi remains controver-
sial (2). Although there are reports of small congenital
nevi progressing to melanoma, such an occurrence is
exceedingly rare in children (3). Melanocytic nevi
covering more than 5% of the total body surface are
associated with high risk of malignant transformation
(4).
The location and size of the nevus, the patient’s age,
and compatibility with the selected method should be
considered when choosing the method of reconstruction.
Several methods of reconstruction have been reported
for the head and neck region, including primary closure,
split-thickness or full-thickness skin grafts, and local and
distant flaps. Local tissues are generally the first choice
for donor sites because they have better matches of tissue
characteristics, texture, and color. When local tissues are
not adequate for reconstruction, distant flaps or tissue
expansion can be used. Tissue expansion may be valuable
in some cases, because it can allow the creation of
enlarged and enhanced local tissue for advancement
or rotation flaps (5).
There are two kinds of expansion; acute, intraopera-
tive and chronic, long term. Both techniques have dif-
ferent properties. In chronic expansion, the overlying
skin is kept under increasing pressure for a long period of
time. Specific histologic, mechanical, and physiologic
changes occur during the course of prolonged tissue
expansion. The requirement of a second operation,
624 Pediatric Dermatology Vol. 29 No. 5 September ⁄ October 2012
physical deformity between sessions, and high incidence
of complications due to tissue expanders could be
counted as disadvantages of chronic expansion (6).
Intraoperative, acute expansion is a different process.
Sasaki has described it as an extension or modification of
chronic expansion and advocates it (7). Typically, acute
expansion involves stretching the skin during a single
operative session. In contrast to long-term expansion,
acute expansion most likely increases the skin length
through mechanical creep and natural extensibility of the
skin. It could be obtained using special devices or simple
instruments such as sutures, wires, or Foley catheters.
Foley catheters as inflatable expanders can provide
omnidirectional expansion, unlike linear skin stretching
devices (8). This is important when distortion of specific
anatomic landmarks needs to be avoided.
Intraoperative expansion has the following advanta-
ges: the absence of a retained, buried foreign body; the
absence of a physical deformity, especially in the head
and neck areas; and the immediate availability of tissue
for reconstruction. The technique is more suitable for the
coverage of small to medium-sized defects than of larger
defects (9).
Tissue expansion can also be used for pediatric pa-
tients in the head and neck region, where particular
emphasis is placed on brow symmetry, temporal hairline
position, and scar orientation. If the surrounding land-
marks such as brow and hairline are not distorted, then
the horizontally oriented scar can still provide an
acceptable outcome (10). In our case, the patient had a
medium-sized congenital melanocytic nevus on the right
supraorbital area close to the midline. We thought that
immediate tissue expansion using a Foley catheter would
be the most appropriate option for our patient because
we would achieve a single-stage closure of the forehead
skin defect with expanded tissue with similar tissue
characteristics. Immediate expansion using a Foley
catheter is not only an inexpensive method, but
also avoids a disadvantage of linear acute skin stretch-
ing technique: the possible distortion of the forehead
hairline.
REFERENCES
1. Sasaki GH. Tissue expansion. West J Med 1989;150:77–
78.
2. Bauer BS, Few JW, Chavez CD et al. The role of tissue
expansion in the management of large congenital pig-
mented nevi of the forehead in the pediatric patient. Plast
Reconstr Surg 2001;107:668–675.
3. Tannous ZS, Mihm MC Jr, Sober AJ et al. Congenital
melanocytic nevi: clinical and histopathologic features, risk
of melanoma, and clinical management. J Am Acad
Dermatol 2005;52:197–203.
4. Swerdlow AJ, English JS, Qiao Z. The risk of melanoma in
patients with congenital nevi: a cohort study. J Am Acad
Dermatol 1995;32:595–599.
5. Hoffmann JF. Tissue expansion in the head and neck.
Facial Plast Surg Clin N Am 2005;13:315–324.
6. Machida BK, Liu-Shindo M, Sasaki GH et al. Immediate
versus chronic tissue expansion. Ann Plast Surg
1991;26:227–231, discussion 232.
7. Sasaki GH. Intraoperative expansion as an immediate
reconstructive technique. Facial Plast Surg 1988;5:362–
378.
8. Auletta MJ, Matarasso SL, Glogau RG et al. Comparison
of skin hooks and foley catheters for immediate tissue
expansion. J Dermatol Surg Oncol 1993;19:1084–1088.
9. Petro JA, Niazi ZBM. Immediate skin expansion: an old
concept by a novel and inexpensive technique. Ann Plast
Surg 1996;36:479–484.
10. LoGiudice J, Gosain AK. Pediatric tissue expansion:
indications and complications. J Craniofac Surg 2003;
14:866–872.