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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): 46–49; http://dx.doi.org/10.18282/jsd. v2.i1.74.
*Correspondence to: Mohammed Mesfer Alkahtani, King Abdulaziz Medical City, Jeddah, Saudi Arabia, email@example.com.
Received: 9th September 2016; Accepted: 7th December 2016; Published Online: 16th January 2017
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. 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
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
face is affected. One must respect the aesthetic
subunits and that may entail the need for serial excision
and hence multiple procedures.
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-
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-
AlKahtani MM, et al.
Postoperatively, the grafted area was hyperpigmented;
however, there was a drastic and gradual improvement
over a period of four weeks in skin pigmentation and
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
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). In addition, cultured epithelial auto-
graft (CEA) has also been employed in the treatment.
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-
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. It proved to be an adequate modality for the
removal of pigmentation in the treatment of large and
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. 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
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-
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.
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.
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
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