ArticlePDF Available

Giant congenital melanocytic nevus - Reconstruction using multiple modalities: A case report

Authors:

Abstract and Figures

p>Congenital melanocytic naevi are neuroectodermal lesions that are mainly composed of melanocytes. They are present in 1% to 6% of all newborns. These lesions carry the risk of transforming into melanomas; however, the psychological effect of such disfiguring naevi is potentially of greater concern to both the child and parent. Several classifications for congenital melanocytic naevi have been proposed, the most common of which is the sub-classification according to their size as this affects the choice of treatment. Many treatment modalities have been utilized including surgical excision followed by reconstruction, curettage, dermabrasion, laser therapy and chemical peels. In this report, we present a case of an otherwise healthy eight-year-old girl with a giant congenital melanocytic naevus on the central face. The lesion was mostly excised with remaining satellite lesions dermabraded. The defect was then reconstructed with a full thickness skin graft harvested from the expanded supraclavicular skin, in addition to the ReCell (non-cultured epithelial autograft) technique. Within six months post-operation, excellent skin pigmentation and texture was achieved.</p
Content may be subject to copyright.
doi: 10.18282/jsd.v2.i1.74
Copyright © 2017 Alkahtani MM, et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution-Non Com-
mercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), permitting all non-commercial use, distribution, and reproduction
in any medium, provided the original work is properly cited.
46
CASE REPORT
Giant congenital melanocytic nevus - Reconstruction using multiple
modalities: A case report
Mohammed Mesfer Alkahtani*, Loujin Asad, Arwa Sindi
Department of Plastic, Reconstructive and Burns Surgery, King Abdulaziz Medical City, Jeddah, Saudi Arabia
Abstract: Congenital melanocytic naevi are neuroectodermal lesions that are mainly composed of melanocytes. They
are present in 1% to 6% of all newborns. These lesions carry the risk of transforming into melanomas; however, the
psychological effect of such disfiguring naevi is potentially of greater concern to both the child and parent.
Several classifications for congenital melanocytic naevi have been proposed, the most common of which is the
sub-classification according to their size as this affects the choice of treatment. Many treatment modalities have been
utilized including surgical excision followed by reconstruction, curettage, dermabrasion, laser therapy and chemical
peels. In this report, we present a case of an otherwise healthy eight-year-old girl with a giant congenital melanocytic
naevus on the central face. The lesion was mostly excised with remaining satellite lesions dermabraded. The defect
was then reconstructed with a full thickness skin graft harvested from the expanded supraclavicular skin, in addition to
the ReCell (non-cultured epithelial autograft) technique. Within six months post-operation, excellent skin pigmentation
and texture was achieved.
Keywords: Congenital facial naevi; ReCell; dermabrasion; tissue expander; melanoma
Citation: Alkahtani MM, Asad L, Sindi A. Giant congenital melanocytic nevus-Reconstruction using multiple modali-
ties: A case report. J Surg Dermatol 2017; 2(1): 4649; http://dx.doi.org/10.18282/jsd. v2.i1.74.
*Correspondence to: Mohammed Mesfer Alkahtani, King Abdulaziz Medical City, Jeddah, Saudi Arabia, drhababi@gmail.com.
Received: 9th September 2016; Accepted: 7th December 2016; Published Online: 16th January 2017
Introduction
Congenital melanocytic naevi (CMN) are neu-
ro-ectodermal lesions that are evident at birth. These
lesions develop between the 5th and 25th weeks of gesta-
tion. They are present in 1% to 6% of all newborns with
an incidence of 1:20,000[1,2].
Several classifications of congenital melanocytic
naevi have been proposed in literature; the most common
of which is the sub-classification according to their an-
ticipated surface diameter in adulthood: small lesions are
those less than 1.5 cm in diameter, medium lesions are
1.5 cm to 20 cm in diameter, and large lesions are more
than 20 cm in diameter[3]. This has been modified to de-
fine large lesions as those that are 11 cm to 20 cm in di-
ameter, and naevi larger than 20 cm are considered as
giant lesions[4].
As there is a risk of malignant degeneration associated
with large and giant CMN (reported to reach up to 12
percent)[5,6], it is common practice to completely excise
such lesions. It is also thought that surgical excision may
reduce the risk of malignant degeneration. However, this
remains a topic of controversy throughout literature.
There is no doubt that surgical excision must be taken
into consideration, as such a disfigurement can be detri-
mental to a child’s psychological development[3,7-10].
When considering surgical excision, the size and site
of the naevus is of tremendous importance in determin-
ing the plan of management[9,11]. This is a much complex
task when an aesthetically important area such as the
Giant congenital melanocytic nevus Reconstruction using multiple modalities: A case report
47
doi:10.18282/jsd.v2.i1.74
face is affected[9]. One must respect the aesthetic
subunits and that may entail the need for serial excision
and hence multiple procedures.
Case presentation
The patient is an eight-year-old girl who is otherwise
healthy with an uncomplicated perinatal history. She
presented with a giant congenital melanocytic hairy
naevus of the nose measuring 15 × 5 cm, increasing in
size since birth. Photography consent was taken from the
parents (Figure 1).
Figure 1. Pre-operative extent of CMN
After multiple counseling sessions with the parents
and child, the decision to proceed with surgery was
reached. The patient was admitted to our institute; con-
sent was obtained from the parents and pre-operative
work-up was done. In the operating theatre, a 5-cm inci-
sion was made over the right supraclavicular groove after
an injection of 1% Xylocaine with 1:100,000 epinephrine.
Meticulous dissection was done and a 75-cc tissue ex-
pander was inserted into the pocket. After that, meth-
ylene blue was injected with an initial 30-cc of normal
saline. A small drain was placed, and removed the fol-
lowing day.
The patient visited the outpatient clinic on a regu-
lar basis and the tissue expander was over-expanded to
100 cc. This was attained over a period of six weeks.
She was then brought back to our institute for total
excision and second stage reconstruction. Consent and
pre-operative work-up were obtained in a similar manner.
She underwent general anesthesia, and after the infiltra-
tion of 40 cc of 1% Xylocaine with 0.25% Marcaine, the
lesion was excised in full thickness (Figure 2).
The majority of the defect was covered by a full
thickness skin graft harvested from the expanded supra-
clavicular skin. In addition to excision, dermabrasion of
the remaining naevus covered area over the nasolabial
folds bilaterally, medial end of the right eyebrow and
right lower lateral cartilage was performed (Figure 3).
Part of the obtained graft was used in ReCell tech-
nique and administered in the coverage of the derm-
abraded areas. The full thickness graft was then fixed
with 4.0 vicryl rapide and bolstered in place, followed by
Tegaderm; the ReCell graft was fixed with cellophane,
followed by steri-strips (Figure 4).
Figure 2. Full thickness excision of CMN centrally located
Figure 3. Dermabrasion over the nasolabial folds bilaterally,
medial end of the right eyebrow and right lower lateral carti-
lage
AlKahtani MM, et al.
48
doi:10.18282/jsd.v2.i1.74
Postoperatively, the grafted area was hyperpigmented;
however, there was a drastic and gradual improvement
over a period of four weeks in skin pigmentation and
texture.
Histopathology report revealed compound nevocellu-
lar naevus with junctional activity and nests of cells in
the upper dermis with maturation in the deep dermis.
At six-month follow-up, a significant improvement
was noted in comparison to her pre-operative presenta-
tion (Figure 5).
Figure 4. Application of full thickness skin graft
Figure 5. 6 months post-operative
Discussion
Treatment of giant congenital melanocytic naevi is
a challenging commitment. Several modalities have been
utilized in their management. The methods of choice
include complete excision followed by reconstruction
(skin graft, tissue expansion, local flaps), and incomplete
excision (chemical peels, laser therapy, dermabrasion
and curettage)[12]. In addition, cultured epithelial auto-
graft (CEA) has also been employed in the treatment[13].
The use of tissue expansion has been incorporated in
the management of large congenital melanocytic naevi
with the use of local advancement and rotation flaps or
as a full thickness skin graft.
Gur and Zuker used tissue expansion in the manage-
ment of facial CMN that are more than 3 cm in diameter.
Their extensive use proved successful with good aes-
thetic results in conjunction with serial excisions and
skin grafting. Scars were planned to lie transversely or
obliquely in a single aesthetic unit and thus be less visi-
ble[11].
Dermabrasion was discovered by Johnson in 1977. He
dermabraded the entire naevus of three patients whose
wounds went on to re-epithelialize without pigmenta-
tion[14]. It proved to be an adequate modality for the
removal of pigmentation in the treatment of large and
giant CMN.
In 2005, ReCell (non-cultured epidermal/dermal au-
tograft) was introduced primarily for the treatment of
partial thickness burns. Its reconstructive applications
have been employed following ablative skin cancer sur-
gery with satisfactory aesthetic results. The use of ReCell
is easy and straightforward. Initially a specimen of split
thickness skin is harvested. Then, it is administered in
trypsin for a duration of 20 minutes. Meanwhile, the
dermabrasion is done and haemostasis is ensured. The
specimen is then removed and the cells are taken from
the dermoepidermal junction zone using a blade.
Suspension of the cells in sodium lactate solution is
performed followed by aspiration, filtration, and finally
application onto the wound[12]. However, cell suspension
is not without disadvantages. The body contour makes it
difficult for the whole concentration of cells to remain
in contact with the wound; thus, early dressing change is
not advised in order to allow the cell suspension to stay
in close proximity with wound. ReCell is superior to
CEA in that it allows for completion of the surgery in a
single procedure with a minimal donor site.
Despite careful excision or dermabrasion of a
giant CMN, the risk of malignant transformation can-
not be ruled out. Thus, regular long-term follow-up is
Giant congenital melanocytic nevus Reconstruction using multiple modalities: A case report
49
doi:10.18282/jsd.v2.i1.74
recommended.
Conclusion
Treating complex congenital melanocytic naevi is chal-
lenging and requires a combination of treatment modali-
ties. Tissue expansion in conjunction with full thickness
skin graft, dermabrasion and ReCell technique allows
for complete excision of a single aesthetic unit and re-
construction in a two-stage, easy, safe and short proce-
dure.
This technique allows for the removal of the melano-
cytic pigment load, and promotes rapid epithelialization
with good pigmentation. It also reduces the risk of ma-
lignant degeneration, improves aesthetic appearance and
potentially reduces psychological stress.
Author contributions
Acquisition of data was done by MM AlKahtani, L Asad
and A Sindi. MM AlKahtani was also involved in
study conception and design, analysis and interpretation
of data, drafting, and critical revision of the manuscript.
Acknowledgments
We would like to thank our colleagues and residents
from the Department of Plastic Surgery, King Abdulaziz
Medical city, Jeddah, Saudi Arabia for their tremendous
effort in patient care and research activities.
Conflict of interest
The authors declare no potential conflict of interest with
respect to the research, authorship, and/or publication of
this article.
References
1. Helmbold P, Rompel R, Petres J, Lübbe D, Marsch WC.
Kongenitale melanozytäre Nävi (German) [Congenital
melanocytic nevi]. Hautarzt 1999; 50(11): 779784. doi:
10.1007/s001050050984.
2. Castilla EE, da Graca Dutra M, Orioli-Parreiras IM. Epi-
demiology of congenital pigmented naevi: II. Risk factors.
Br J Dermatol 1981; 104(4): 421427. doi: 10.1111/j.
1365-2133.1981.tb15312.x.
3. Kopf AW, Bart RS, Hennessey P. Congenital nevocytic
nevi and malignant melanomas. J Am Acad Dermatol
1979; 1(2): 123130. doi: 10.1016/S0190-9622(79)70009-0.
4. Ruiz-Maldonado R. Measuring congenital melanocytic
nevi. Pediatr Dermatol 2004; 21(2): 178179. doi:
10.1111/j.0736-8046.2004.21222.x.
5. Zaal LH, Mooi WJ, Klip H, van der Horst CM. Risk of
malignant transformation of congenital melanocytic nevi:
A retrospective nationwide study from The Netherlands.
Plast Reconstr Surg 2005; 116(7): 19021909. doi:
10.1097/01.prs.0000189205.85968.12.
6. Quaba AA, Wallace AF. The incidence of malignant mel-
anoma (0 to 15 years of age) arising in ―large‖ congenital
nevocellular nevi. Plast Reconstr Surg 1986; 78(2): 174
181. doi: 10.1097/00006534-198608000-00004.
7. Bauer BS, Vicari FA. An approach to excision of congen-
ital giant pigmented nevi in infancy and early childhood.
Plast Reconstr Surg 1988; 82(6): 10121021. doi:
10.1097/00006534-198812000-00012.
8. Pilney FT, Broadbent TR, Woolf RM. Giant pigmented
nevi of the face: Surgical management. Plast Reconstr
Surg 1967; 40(5): 469474. doi: 10.1097/00006534-
196711000-00009.
9. Sbitany U, Caldwell EH. Treatment of a giant congenital
hairy nevus of the ear. Plast Reconstr Surg 1986; 78(2):
242244. doi: 10.1097/00006534-198608000-00019.
10. Weinberg MJ, Mahoney JL. Wound suturing—―How do I
do it?‖ Univ Tor Med J 1989; 66(3): 21–27.
11. Gur E, Zuker RM. Complex facial nevi: A surgical algo-
rithm. Plast Reconstr Surg 2000; 106(1): 2535. doi:
10.1097/00006534-200007000-00005.
12. O’Neill TB, Rawlins J, Rea S, Wood F. Treatment of a
large congenital melanocytic nevus with dermabrasion
and autologous cell suspension (ReCELL®): A case report.
J Plast Reconstr Aesthet Surg 2011; 64(12): 16721676.
doi: 10.1016/j.bjps.2011.05.016.
13. Whang K, Kim M, Song W, Cho S. Comparative treat-
ment of giant congenital melanocytic nevi with curettage
or Er:YAG laser ablation alone versus with cultured epi-
thelial autografts. Dermatol Surg 2005; 31(12): 1660
1667. doi: 10.2310/6350.2005.31305.
14. Johnson HA. Permanent removal of pigmentation from
giant hairy naevi by dermabrasion in early life. Br J Plast
Surg 1977; 30(4): 321323. doi: 10.1016/0007-1226(77)
90131-X.
ResearchGate has not been able to resolve any citations for this publication.
Article
Congenital melanocytic naevi (CMN) are present at birth in between 1 and 6% of all neonates. They are caused by malformations of the neuroectoderm that are comprised of melanocytes and occasionally neural elements, following dysregulated growth and arrest of melanocytes during migration from the neural crest to the skin. Most commonly they are sub-classified according to size. They are at risk of malignant transformation, but the psychological impact of prominent CMN's is arguably of greater potential concern to the parent and child. Treatment modalities to date have included complete surgical excision with defect reconstruction, as well as less invasive methods such as dermabrasion, curretage, chemical peels and laser therapy. We present an illustrated case of a healthy, term, 4 week-old male neonate with a large CMN on his face. The lesion was dermabraded, and non-cultured epithelial autograft harvested from the right post-auricular area was applied. Dressings were no longer required by the 8th post-operative day, and excellent skin pigmentation and texture was achieved by 5 months post-op.
Article
The subject of the relationship between congenital nevocytic nevi and malignant melanomas has many controversial aspects. Data are insufficient to come to firm conclusions concerning how often melanomas supervene in such nevi and to determine the prognosis of those melanomas. What data are available indicate that malignant melanomas develop in a substantial percentage of large (giant) nevocytic nevi. This lends support to those who recommend surgical excision of such large lesions, when feasible. On the other hand, the information currently available concerning the association of malignant melanomas with medium- and small-sized congenital nevocytic nevi (i.e., those less than 20 cm in larges diameter) is scanty. Because of this lack of data on congenital nevocytic nevi, our current approach is to take into consideration the probability of cosmetic improvement by surgical removal in conjunction with education of the patient and/or family that malignant melanomas have been known to occur in congenital nevocytic nevi but are probably rare except in nevi of large size. Such information provided to the patient and/or family will often help in making the decision for removal or continued observation. A Congenital Nevocytic Nevus Registry has been established in the Oncology Section of the Skin and Cancer Unit at New York University Medical Center in the attempt to begin a long-term prospective study which might eventually provide some meaningful information concerning the natural history of such lesions, including the incidence of malignant melanomas.
Article
A split-thickness skin graft from the abdomen was successfully used to resurface the entire auricle following full-thickness excision of a congenital nevocellular nevus. We found no previous report describing the use of skin grafts to successfully resurface the entire ear and achieve an acceptable aesthetic result.
Article
Genetic and environmental risks factors were investigated in a sample of 989 non-malformed newborn infants with skin pigmented naevi (PN), and in 989 non-malformed non-PN, control babies. The samples were obtained from a population of 531,831 livebirths, from fifty-nine South-American maternity hospitals. No significant differences were observed between the PN and control groups for the following risk factors: sex, twinning, parental consanguinity, socioeconomic level, parental ages, birth order, fetal presentation, type of delivery, postnatal mortality, and first trimester of pregnancy histories for maternal chronic illnesses or immunizations, radiation exposure, drug intake, and vaginal bleeding. PN infants were associated with high frequencies of Black racial ancestry, positive prenatal history for maternal acute illnesses, and high mean values for length of gestation and birth weight. The observed association of PN with maternal acute illnesses could be a spurious one, due to partial dependence upon Black racial ancestry, and to maternal memory bias. The analysis of the intrauterine growth curves showed that PN infants have a low prematurity rate, and a high mean by the control newborn group. This observation suggest that congenital PN appear in the latest stages of intrauterine development. No evidence was obtained to allow us to consider congenital PN as true developmental anomalies.
Article
Congenital melanocytic nevi are benign skin tumours with a population-based prevalence of 1-6%. They run an increased life-time risk of transformation into malignant melanoma. Additionally, they can be associated with an involvement of the leptomeninges (neurocutaneous melanosis), and may cause considerable cosmetic and psychic problems. In contrast to the past, the risk of congenital melanocytic nevi developing into melanoma is now regarded as well-established. Thus, excision is recommended whenever possible. Large lesions which do not allow complete excision should be treated by dermabrasion within the first weeks of life.
Article
Sixty-six children with large congenital nevi of the face were surgically managed in our center during the last 8 years. All patients with a lesion that posed a reconstructive challenge were included in the study. None could be effectively dealt with by excision and simple primary closure. To simplify description and evaluation, the patients were divided into three groups. Group I had 15 patients with relatively small lesions (1- to 3-cm maximal diameter) that were confined to one aesthetic unit of the face and could be reconstructed in one stage. Reconstruction was usually achieved by using local skin flaps or with full-thickness skin grafting. Group II had 28 patients with medium-sized lesions (3- to 12-cm maximal diameter) that involved one or two aesthetic units and required not more than two stages for reconstruction. These patients usually needed either serial excisions and/or skin grafting or a two-stage tissue expansion procedure (insertion of tissue expanders and reconstruction). Group III had 23 patients with very large lesions (over 12 cm in maximal diameter), some covering half of the face and thus involving several aesthetic units and requiring multiple stages for reconstruction. These patients required a combination of tissue expansion procedures, large faciocervical and scalp/forehead skin flaps, full-thickness skin grafting, and serial excisions for reconstruction. The anatomic distribution of the lesions over the various aesthetic units is described, as are the reconstructive techniques with advantages and disadvantages of each, reflecting on outcome. The approach to the larger complex lesions is detailed. Based on our experience, a reconstructive algorithm is proposed.