Giant congenital melanocytic nevi are large pigmented disfiguring skin lesions that are present at birth and that have a significant risk of developing malignant melanoma. In addition, these lesions result in significant psychological distress for both the patient and their family. These lesions occur at a rate of approximately one in 20,000 births and can involve the trunk, extremities, head, neck, and face. While these lesions are always present at birth, the extent of the lesions may not be initially appreciated due to changes in size, shape, and pigmentation over time.
The risk of developing melanoma skin cancer in these lesions over time has been recorded to be in the range of 2.8 to 8.5%.
This is a significantly higher risk than the risk in the general population and it is the main reason why complete surgical excision is generally recommended. The second reason why complete surgical excision is recommended is related to the severe psychological distress associated with these large pigmented skin lesions, especially those that involve the face.
The treatment of children with giant congenital melanocytic nevi presents a unique reconstructive challenge that should only be undertaken by a board-certified plastic surgeon with extensive additional training and experience in craniofacial surgery and pediatric plastic surgery. Dr. Robert Morin is a Board-Certified Plastic Surgeon with extensive additional training and experience in both Craniofacial surgery and pediatric plastic surgery.
The goals of surgical excision are to decrease the risk of malignant melanoma, improve the aesthetic appearance of the patient, and to maintain psychosocial well-being. Treatment modalities include serial excision where smaller portions of a large lesion are excised and directly closed over the course of several surgeries performed over time.
Tissue expansion is another extremely effective way of using extra skin to reconstruct areas where the skin has been excised. Skin grafting is also an effective way of replacing giant congenital melanocytic nevi with normal-appearing skin.
Many minimally invasive techniques have been described, however, these techniques leave cells behind and obscure the ability to monitor the patient for the development of skin cancer. As a result, these techniques are generally not recommended. Regardless of the type of reconstruction performed, the goal of surgery in children with giant congenital melanocytic nevi is to have the surgical treatment completed by the time the child begins school.
The patient seen below is one of Dr. Morin’s patients with a giant congenital nevus involving her face and scalp. The patient underwent many surgical procedures over the course of several years in order to excise the giant congenital nevus from her face and to reconstruct her face using a combination of serial excision, tissue expansion, and skin grafting.
The photographs below demonstrate in detail the patient’s surgical journey from the initial diagnosis to school age. Surgery was begun early in this patient’s life in order to decrease her risk of melanoma and also to provide an aesthetically pleasing reconstruction by the time the patient entered school.
Here you can see the patient at a very young age during her initial consultation. At that time, a giant congenital melanocytic nevus involving the face and scalp was diagnosed and a surgical plan was discussed with the patient’s parents.
In this image you can see how these lesions evolve over time when the patient is young, both increasing in size and darkening in pigmentation.
This photograph shows the patient after an initial serial excision was performed. The borders of the lesion were excised in order to create the ideal shape in preparation for tissue expansion.
Here you can see the patient prior to her tissue expansion after several serial excisions had been performed.
The tissue expander is filled with normal saline over the course of several months to expand the overlying skin.
This is the result following the removal of the tissue expander and the reconstruction of her left cheek using the expanded skin.
In this photograph, you see the patient after additional excisions and full-thickness skin grafting to the left lower eyelid and nose.
In this photograph, you see the patient after additional excisions and full-thickness skin grafting to the left lower eyelid and nose.
This is a photograph of the patient after more excisions and additional full-thickness skin grafting involving the nose.
Here you can see the patient’s result after additional excisions and full-thickness skin grafting to the nose.
Final Excision and Full-Thickness Skin Grafting Results
The before and after photograph below shows the patient before and after her surgical treatment performed entirely by Dr. Robert Morin. This before and after photograph demonstrates a beautiful result with near complete excision of the giant congenital nevus from the patient’s face and an aesthetically pleasing reconstruction.
The risk of malignant transformation has been determined to be greatest in early childhood. For that reason, surgical excision has been recommended in children as young as six months of life. Contact Dr. Morin’s office for more information on ideal treatment options for giant congenital nevus.
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