Letter to the Editor
A Peculiar Case of Facial Congenital Nevus Mario F. Scaglioni, MD1
M.T Bauer, MBBS2
Alberto Di Giuseppe, MD1
1 Department of Plastic and Reconstructive Surgery, Ospedali Riuniti di
Ancona, Univerista’ Politecnica delle Marche, Ancona, Italy 2 Department of Dermatology, University Hospital Frankfurt, Goethe University Frankfurt, Germany
Address for correspondence Mario F. Scaglioni, MD, Department of Plastic and Reconstructive Surgery, Ospedali Riuniti di Ancona, Univerista’ Politecnica delle Marche, Ancona, Italy (e-mail: [email protected]).
Facial Plast Surg 2014;30:468–470.
Abstract Keywords
► facial congenital nevus ► cheek reconstruction ► free ALT flap
Reconstruction of congenital nevi is difficult and challenging, but becomes even more so when they occur on the face due to functional and aesthetic reasons. Traditionally, these lesions have been treated with tissue expansion, sequential resection, and local flap closure with or without skin grafts. Here, we present a case reconstructing a large facial defect involving the entire cheek facial subunit following excision of a giant congenital nevus with a free anterolateral thigh flap.
Giant congenital melanocytic nevi are rare neuroectodermal lesions that occur in 1% of infants and are associated with increased risk of malignant melanoma and neurocutaneous melanosis. The reported risk of malignant melanoma varies from 2.8% to 8.5% and is associated with multiple lesions, lesions larger than 20 cm, and younger patients. The standard treatment has been typically centered on serial excisions with the use of tissue expansion and skin grafting. Here, we present a case using free tissue transfer to reconstruct a giant facial congenital nevus.
Clinical Case A 25-year-old man was referred to our clinic with a giant congenital nevus (12.5 7 cm) on the right cheek (►Figs. 1 and 2). A two-team approach was employed with a resecting team that achieved clear margins of the lesion and isolated the facial vessels as recipient vessels while the second team elevated an anterolateral thigh (ALT) flap. An ALT flap (13 8 cm) was harvested from the right thigh and used to resurface the entire cheek subunit (►Figs. 3 and 4). The patient was discharged after 6 days without complication. Postoperatively, the patient had a reasonable aesthetic result with an acceptable shape and contour comparable to the contralateral side (►Figs. 5 and 6). Unfortunately, because of the natural differences between the skin of the thigh and face, a color discrepancy persists despite the benefits provided by the volume and contour of the ALT flap.
Issue Theme Facets of Facelifting; Guest Editor, Daniel E. Rousso, MD, FACS
Discussion The treatment of congenital nevus is a challenging endeavor particularly for larger lesions located on esthetically sensitive areas such as the face. There have been several studies describing different approaches for treating these lesions based on the size and location of the nevus. Bauer was the first to propose an algorithm using anatomic regions for the management of large nevus to minimize the number of procedures while maximizing cosmetic and functional outcomes. Subsequently, others have proposed a similar algorithm incorporating the subunit principle for reconstruction of giant congenital nevi involving the face which has been progressively modified to account for the number of subunits involved and number of stages needed to complete the reconstruction. Resection and reconstruction of congenital nevus is necessary not only for the esthetic deformity with its associated psychological benefits, but there is also a clear association with the risk of progression to malignant melanoma. As the risk of malignant degeneration increases with age, early treatment is recommended. Fortunately, histological analysis of the specimen from our patient who presented at 25 years of age demonstrated only enlarged melanocytes on pathology without any malignant melanoma. Because of the patient’s age and the large size of the lesion involving, his entire cheek subunit as well as a portion of the lateral forehead, an extensive reconstruction was planned. The patient declined
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1383557. ISSN 0736-6825.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
468
A Peculiar Case of Facial Congenital Nevus
Scaglioni et al.
469
Fig. 1 Preoperative picture frontal view: Giant congenital nevus of the face.
Fig. 4 Intraoperative picture: the flap was inset on the right cheek.
Fig. 2 Preoperative picture lateral view: Giant congenital nevus involving the whole right cheek unit and partial of the lower lateral forehead subunit.
tissue expansion and serial excision with skin grafting because of inability to undergo multiple operations and the deformity associated with tissue expanders which are why we abandoned traditional algorithms. Therefore, we opted to proceed with a single-stage reconstruction using an ALT free
Fig. 5 A 1-year follow-up picture: two-third view.
Facial Plastic Surgery
Vol. 30
No. 4/2014
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Fig. 3 Anterolateral thigh free flap was harvested from the right thigh.
A Peculiar Case of Facial Congenital Nevus
Scaglioni et al. flap which provided appropriate bulk for volume replacement and adequate surface area. In our case, we successfully reconstructed a large congenital nevus defect involving two facial subunits using a free flap in a single stage. The patient was discharged after an uncomplicated hospital stay, and is ambulating without donor site morbidity or hypertrophic scarring or ectropion of the recipient site.
Conclusion In select cases, free flaps represent a reasonable and valid option for the treatment of large congenital nevi. Flap selection should be based on the size of the defect and the volume needed to restore facial contour and symmetry.
Disclosure The authors have no financial conflicts or commercial associations to disclose.
Fig. 6 A 1-year follow-up picture: lateral view.
Facial Plastic Surgery
Vol. 30
No. 4/2014
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
470
Copyright of Facial Plastic Surgery is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
A Peculiar Case of Facial Congenital Nevus Mario F. Scaglioni, MD1
M.T Bauer, MBBS2
Alberto Di Giuseppe, MD1
1 Department of Plastic and Reconstructive Surgery, Ospedali Riuniti di
Ancona, Univerista’ Politecnica delle Marche, Ancona, Italy 2 Department of Dermatology, University Hospital Frankfurt, Goethe University Frankfurt, Germany
Address for correspondence Mario F. Scaglioni, MD, Department of Plastic and Reconstructive Surgery, Ospedali Riuniti di Ancona, Univerista’ Politecnica delle Marche, Ancona, Italy (e-mail: [email protected]).
Facial Plast Surg 2014;30:468–470.
Abstract Keywords
► facial congenital nevus ► cheek reconstruction ► free ALT flap
Reconstruction of congenital nevi is difficult and challenging, but becomes even more so when they occur on the face due to functional and aesthetic reasons. Traditionally, these lesions have been treated with tissue expansion, sequential resection, and local flap closure with or without skin grafts. Here, we present a case reconstructing a large facial defect involving the entire cheek facial subunit following excision of a giant congenital nevus with a free anterolateral thigh flap.
Giant congenital melanocytic nevi are rare neuroectodermal lesions that occur in 1% of infants and are associated with increased risk of malignant melanoma and neurocutaneous melanosis. The reported risk of malignant melanoma varies from 2.8% to 8.5% and is associated with multiple lesions, lesions larger than 20 cm, and younger patients. The standard treatment has been typically centered on serial excisions with the use of tissue expansion and skin grafting. Here, we present a case using free tissue transfer to reconstruct a giant facial congenital nevus.
Clinical Case A 25-year-old man was referred to our clinic with a giant congenital nevus (12.5 7 cm) on the right cheek (►Figs. 1 and 2). A two-team approach was employed with a resecting team that achieved clear margins of the lesion and isolated the facial vessels as recipient vessels while the second team elevated an anterolateral thigh (ALT) flap. An ALT flap (13 8 cm) was harvested from the right thigh and used to resurface the entire cheek subunit (►Figs. 3 and 4). The patient was discharged after 6 days without complication. Postoperatively, the patient had a reasonable aesthetic result with an acceptable shape and contour comparable to the contralateral side (►Figs. 5 and 6). Unfortunately, because of the natural differences between the skin of the thigh and face, a color discrepancy persists despite the benefits provided by the volume and contour of the ALT flap.
Issue Theme Facets of Facelifting; Guest Editor, Daniel E. Rousso, MD, FACS
Discussion The treatment of congenital nevus is a challenging endeavor particularly for larger lesions located on esthetically sensitive areas such as the face. There have been several studies describing different approaches for treating these lesions based on the size and location of the nevus. Bauer was the first to propose an algorithm using anatomic regions for the management of large nevus to minimize the number of procedures while maximizing cosmetic and functional outcomes. Subsequently, others have proposed a similar algorithm incorporating the subunit principle for reconstruction of giant congenital nevi involving the face which has been progressively modified to account for the number of subunits involved and number of stages needed to complete the reconstruction. Resection and reconstruction of congenital nevus is necessary not only for the esthetic deformity with its associated psychological benefits, but there is also a clear association with the risk of progression to malignant melanoma. As the risk of malignant degeneration increases with age, early treatment is recommended. Fortunately, histological analysis of the specimen from our patient who presented at 25 years of age demonstrated only enlarged melanocytes on pathology without any malignant melanoma. Because of the patient’s age and the large size of the lesion involving, his entire cheek subunit as well as a portion of the lateral forehead, an extensive reconstruction was planned. The patient declined
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1383557. ISSN 0736-6825.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
468
A Peculiar Case of Facial Congenital Nevus
Scaglioni et al.
469
Fig. 1 Preoperative picture frontal view: Giant congenital nevus of the face.
Fig. 4 Intraoperative picture: the flap was inset on the right cheek.
Fig. 2 Preoperative picture lateral view: Giant congenital nevus involving the whole right cheek unit and partial of the lower lateral forehead subunit.
tissue expansion and serial excision with skin grafting because of inability to undergo multiple operations and the deformity associated with tissue expanders which are why we abandoned traditional algorithms. Therefore, we opted to proceed with a single-stage reconstruction using an ALT free
Fig. 5 A 1-year follow-up picture: two-third view.
Facial Plastic Surgery
Vol. 30
No. 4/2014
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Fig. 3 Anterolateral thigh free flap was harvested from the right thigh.
A Peculiar Case of Facial Congenital Nevus
Scaglioni et al. flap which provided appropriate bulk for volume replacement and adequate surface area. In our case, we successfully reconstructed a large congenital nevus defect involving two facial subunits using a free flap in a single stage. The patient was discharged after an uncomplicated hospital stay, and is ambulating without donor site morbidity or hypertrophic scarring or ectropion of the recipient site.
Conclusion In select cases, free flaps represent a reasonable and valid option for the treatment of large congenital nevi. Flap selection should be based on the size of the defect and the volume needed to restore facial contour and symmetry.
Disclosure The authors have no financial conflicts or commercial associations to disclose.
Fig. 6 A 1-year follow-up picture: lateral view.
Facial Plastic Surgery
Vol. 30
No. 4/2014
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
470
Copyright of Facial Plastic Surgery is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
![[Congenital giant nevus: report of a case].](/assets/img/hold.png)
