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Background: Congenital pigmented nevi of the auricle are uncommon. The authors' approach is to excise these nevi and perform reconstruction because of the risk of malignant transformation and the aesthetic and psychological effects these nevi can have on the child. This study presents the authors' experience in treating congenital nevi of the ear and suggests treatment principles and guidelines for the reconstructive surgeon. Methods: Fourteen patients with congenital nevus of the ear were treated from October of 1992 to September of 2008 by the senior surgeon (B.S.B.). Nevi involving the more stable areas such as the concha can be resected and grafted early; the antihelix, scapha, and triangular fossa area can be resected and grafted next; and the helical rim, having the most easily distorted cartilage, should be treated last. Lobule reconstruction requires combined flaps and a dermal fat graft or a postauricular fascial fat flap. Results: Successful reconstruction was achieved in 10 patients. Three patients require final revision procedures (lobule reconstruction). One patient, early in our series, developed a deformed helical rim resulting from skin grafting at age 16 months, before the cartilage was firm enough to withstand the contraction forces of the skin graft. All subsequent patients with helical rim involvement had treatment delayed until the ear was at or near completion of its growth. Conclusions: Congenital nevi of the ear present a challenging reconstruction surgeon. The authors developed a treatment plan that breaks the ear down to aesthetic units and considers the location of the nevus, patient age, and the firmness of the cartilage.

Background The surgical treatment of large and giant congenital pigmented nevi of the lower extremity is a challenging endeavor with limited reconstructive options. Methods Fifty large (>10 cm) and giant (>20 cm) congenital pigmented nevi of the lower extremity treated by the senior author (B.S.B.) over a 25-year period were reviewed. All of these nevi were too large for serial excision or direct closure. Results A reconstructive algorithm based on the extent and location (thigh, knee, popliteal fossa, leg, and foot) of the nevus is proposed. The approach to each anatomical region is described in detail, along with nuances of tissue expansion in the extremities. Conclusions Treating large and giant congenital pigmented nevi of the lower extremity requires careful planning and often multiple stages. An evolution of the authors' approach to these lesions has led to improved outcomes. Contour and the limiting of scar contracture around the joints are of paramount importance.

The authors present a cohort of 21 consecutive patients who had congenital pigmented nevi covering 15 to 65 percent of the forehead and adjacent scalp and who were treated at their institution within the last 12 years. All patients were treated with an expansion of the adjacent texture- and color-matched skin as the primary modality of treatment. The median age at presentation was approximately 1 year; mean postoperative follow-up was 4 years. Nevi were classified according to the predominant anatomic areas they occupied (temporal, hemiforehead, and midforehead/central); some of the lesions involved more than one aesthetic subunit. The authors propose the following guidelines: (1) Midforehead nevi are best treated using an expansion of bilateral normal forehead segments and advancement of the flaps medially, with scars placed along the brow and at or posterior to the hairline. (2) Hemiforehead nevi often require serial expansion of the uninvolved half of the forehead to minimize the need for a back-cut to release the advancing flap. (3) Nevi of the supraorbital and temporal forehead are preferentially treated with a transposition of a portion of the expanded normal skin medial to the nevus. (4) When the temporal scalp is minimally involved with nevus, the parietal scalp can be expanded and advanced to create the new hairline. When the temporoparietal scalp is also involved with nevus, a transposition flap (actually a combined advancement and transposition flap because the base of the pedicle moves forward as well) provides the optimal hair direction for the temporal hairline and allows significantly greater movement of the expanded flap, thereby minimizing the need for serial expansion. (5) Once the brow is significantly elevated on either the ipsilateral or contralateral side from the reconstruction, it can only be returned to the preoperative position with the interposition of additional, non-hair-bearing forehead skin. Expansion of the deficient area alone will not reliably lower the brow once a skin deficiency exists. (6) In general, one should always use the largest expander possible beneath the uninvolved forehead skin, occasionally even carrying the expander under the lesion. Expanders are often overexpanded.

A variety of treatment options exists for the management of giant congenital nevi. Confusion over appropriate management is compounded because not all giant congenital nevi are pigmented, and malignant potential varies between different types. The present study sought to define factors in the presentation of giant congenital nevi that could provide an algorithm for their management, with respect to both the extent of resection and subsequent reconstructive options.A retrospective review of all patients who presented with a congenital nevus of 20 cm2 or greater since 1980 was performed, distinguishing among nevi involving the head and neck, the torso, and the extremities. Sixty-one patients with giant congenital nevi were evaluated (newborn to age 16 years), of which 60 nevi in 55 patients have been operated on. Giant congenital nevi having malignant potential were pigmented nevi (53 patients) and nevus sebaceus (four patients). Those not having malignant potential were verrucous epidermal nevi (three patients) and a woolly hair nevus (one patient). Of the 60 giant congenital nevi operated on, expanded flaps were used in 25, expanded full-thickness skin grafts were used in 10, split-thickness or nonexpanded full-thickness skin grafts were used in 13, and serial excision was used in 30. After 1989, operations tended to use multimodality treatment plans, with an increased use of expanded full-thickness grafts and immediate serial tissue expansion. The use of serial excision, particularly in the extremities, also increased after 1989. Serial excision was the treatment of choice when it could be completed in two procedures or less, which occurred in more than 80 percent of cases using serial excision alone. Expanded flaps were the most common mode of reconstruction in the head and neck region and were used in 49 percent of these procedures. Serial excision was the most common form of treatment in the extremities, used in 50 percent of procedures. Tissue expansion in the extremities was infrequently used to provide an expanded flap (8 percent of procedures), whereas it was frequently used to provide expanded full-thickness skin grafts harvested from the torso (used in 31 percent of procedures). On the basis of these data, algorithms for the extent of resection and subsequent reconstructive options for giant congenital nevi were developed. Their management should be formulated relative to pigmentation, malignant potential, and anatomic location of the respective lesions.

Three children with giant pigmented nevi were treated by repeated tissue expansion. Five flaps were expanded twice, and one flap was expanded three times. The delay between expansions was 4 to 15 months (mean 9 months). With full inflation, vascularization of the flap remained good. However, every new expansion decreased flap length by 50 percent. Overall results with this technique, especially in two infants with giant pigmented nevi involving respectively 20 and 40 percent of the body surface, have been most impressive. Only one major complication has occurred: erosion of the skin caused by a fold of the expander envelope resulting in exposure of the expander. This technique improves the early surgical management of giant pigmented nevi and may provide better long-term functional and cosmetic results.

An unusual giant pigmented nevus, containing lymphocytic infiltrates and apparent muscle invasion, but without the presence of melanoma, is described in detail--including its related immunological parameters. The controversy concerning the malignant potential of giant pigmented nevi, and the paradoxes that are encountered clinically, are discussed.

This paper presents a timely coordinated approach to complete excision of congenital giant pigmented nevi in infancy and early childhood based on a review of 78 patients with giant pigmented nevi of the head and neck, trunk, and/or extremity. Giant pigmented nevi in those selected for review measured from a minimum of 2 percent up to 45 percent total body surface (TBS). Giant nevi of the scalp were treated most effectively using tissue expansion, beginning as early as 3 months of age. Expanded forehead and neck flaps in combination with expanded full-thickness skin grafts were used in early excision of giant pigmented nevi of the face. Giant nevi of the trunk were treated using a combination of abdominoplasty technique, tissue expansion, and split-thickness skin graft, with early "large segment" excision and grafting being the most effective treatment of giant nevi covering the posterior trunk. Giant nevi of the extremities were treated most effectively with excision and graft. Expanded full-thickness skin grafts gave excellent coverage on the hands and feet.

• Solitary small very dark and papular pigmented nevi, less than 4 mm, are seen commonly in the second decade of life and have a distinctive histologic pattern. Microscopically these lesions show abundant intraepidermal melanin, included within the keratin layer, and proliferating single melanocytes or nevus cell nests. Prominent nucleoli in the melanocytic cells, occasional mitoses, and the invariable presence of moderate numbers of dermal melanophages and lymphocytes indicated the activity of the pathologic process. The benignity of the lesions in nine patients is supported by a benign course over a one-to three-year evaluation period after limited excisional biopsy procedures. The clinical and pathologic evidence of activity in these nevi suggests yet another possible precursor of malignant melanoma. The B-K mole syndrome and the dysplastic nevi syndrome differ from these cases both clinically and histologically. ( Arch Dermatol 1983;119:35-38)

Routine excision of pigmented nevi in certain anatomic locations such as the palms and soles has been advocated as a prophylactic measure in the prevention of malignant melanoma. To determine the incidence and anatomic distribution of nevi on palms, soles, nailbeds, and conjunctivae, 1,000 randomly selected subjects were examined clinically. Over-all incidence of one or more plantar nevi was 9%; palmar nevi, 5.8%; and conjunctival nevi, 0.8%. No nevi were found in the nailbeds of white subjects. Greatest concentration of plantar nevi was in the arch region. Darker-skinned ethnic groups and male subjects showed the highest incidence. The incidence increased progressively in the first two decades of life, reached a peak in the third, and declined thereafter. Because of their frequency, it is concluded that routine excision of pigmented nevi on palms and soles is infeasible and unwarranted.

• An attempt is made to state the clinical features by which the physician can decide whether a common pigmented mole, appropriately designated as a melanocytic nevus, should be removed. At the junction or interface between epidermis and dermis lie the melanocytes whose multiplication and extrusion into the dermis is called junctional activity. Junctional activity is considered to be a necessary prerequisite for the development of melanoma when it arises from a preexisting nevus. Polypoid, dome-shaped, sessile, and pedunculated lesions are usually free from this histological feature, but flat lesions, slightly elevated lesions, elevated lesions with pigmented halos, and verruciform lesions are likely to have junctional activity. These latter types should, if treated at all, be totally excised and examined histologically.