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What is giant nevi removal surgery?

Children can be born with pigmented moles called congenital nevi (or nevus, if singular). These represent a proliferation of melanocytes, the pigment-producing cells of the skin. When they occur, congenital melanocytic nevi can be highly varied in size and shape. They may be very small and insignificant in appearance to very big, covering large areas of the body. Small congenital nevi are those less than 1.5 cm in size. Giant nevi are those measuring 20cm or more in size at birth. The goal of giant nevi removal surgery is to remove the mole in its entirety or at least as much as is possible.

Congenital nevi, including giant nevi, are generally considered to occur sporadically, in a completely unpredictable fashion. Small congenital nevi are seen in 1 in 100 births whereas giant nevi occur much more infrequently – 1 in 20,000 births. These moles (also known as melanocytic nevi) are usually brown in colour. That colour may be uniform or very irregular with darker areas mixed with lighter areas. Congenital nevi can also have thickened or raised areas, texture differences, and excessive hair growth. Because excess hair growth is common, these lesions are sometimes alternately referred to as giant hairy nevi. While giant congenital nevi can occur at any body site, there is a predilection for them to appear on the trunk, including the back, abdomen, hips, and buttocks. The scalp and face are also frequently involved.

Congenital nevi are believed to have an increased risk of malignant transformation over the lifetime of the child. Small- and medium-sized congenital melanocytic nevi have a risk as low as 1% or less. Large and giant melanocytic nevi have a higher risk of 5-10% over the child's lifetime. As the child reaches puberty, congenital melanocytic nevi can develop additional changes creating a worsened appearance due to thickening, darkening, or ulcerations of any part of the entire lesion.

Giant nevi can be challenging to effectively manage. There is often a sense of urgency to remove the external lesion for both medical and cosmetic reasons. The large size of these lesions means they usually cannot be removed all at once to allow for primary healing of the excised areas. Many techniques have been developed to provide adequate tissue for the closure of the surgical wound that is created by removing the nevi. Most commonly this includes tissue expansion and grafting.

"Surgeons who have the necessary training, expertise, and experience in reconstructive surgery are fit to perform cosmetic surgeries with excellent outcomes. Those surgeons only trained in aesthetic procedures will have much more difficulty doing the same. The more tools and training in plastic surgery the surgeons have, the more qualified they are! "

Who is a good candidate for giant nevi removal?

In general, children who are born with congenital melanocytic nevi are recommended to be followed regularly by a dermatologist who can monitor the lesion for concerning changes. Dermatologists may subsequently refer a patient to a plastic surgeon for a consultation regarding the removal of the lesion. Removal is usually recommended for symptomatic lesions that ulcerate or are excessively itchy. Lesions with atypical changes in size, shape, appearance, or texture are also recommended for excision to prove the lesion is still benign and to prevent further risk of malignant degeneration. Families may also not like how the lesion looks and desire removal for cosmetic reasons as well.

Removal of a congenital nevus is a highly individualized procedure due to the variable shape, size, and location of these types of lesions. Typically surgery is started sometime during childhood to promote healing and avoid natural enlargement as the child grows and the potential for malignancy changes over time.

In general, your child may be a good candidate for giant nevi removal surgery if physically healthy and at a stable weight, the lesion is of a size and location that is amenable to removal and has symptoms of pain, ulceration or itching, or has developed other atypical features; and if you, as a parent, has realistic expectations and a good understanding of the proposed series of necessary procedures.

What should I expect during a consultation for giant nevi removal?

The success and safety of giant nevi removal surgery start with a consultation with Dr Ricardo and depends very much on your complete candidness. During your giant nevi removal surgery consultation be prepared to discuss your surgical goals, options available to remove the nevus, and reconstruct the associated defect, medical conditions, drug allergies, and medical treatments; current medications, vitamins, herbal supplements, alcohol, tobacco, and drug use; and previous surgeries.

Dr Ricardo will also evaluate your general health status and any pre-existing health conditions or risk factors, examine your or your child, take photographs, discuss the approach to your surgery, including the type of procedure or combination of procedures and tell you whether your expectations are in line with typical results, discuss any risks or potential complications and share before-and-after photos of cases similar to yours.

It's very important to understand all aspects of your procedure. It's natural to feel some anxiety, whether it's excitement about your anticipated new look or a bit of preoperative stress. Don't be shy about discussing these feelings with Dr Ricardo.

How should I prepare for giant nevi removal?

In preparing for giant nevi removal surgery, Dr Ricardo may recommend lab or radiographic testing, or a special medical evaluation, certain medications or adjusting current medications, and avoiding aspirin, anti-inflammatory drugs, and herbal supplements as they can increase bleeding.

Surgery to remove a giant congenital nevus is typically performed in a hospital and will likely use general anaesthesia. Children undergoing surgery will need to be closely monitored at home for healing and general recovery from anaesthesia.

Dr Ricardo and the entire staff will provide thorough preoperative instructions and answer any questions you may have. The goal is to make the surgical experience as easy, comfortable, and safe as possible.

What are the techniques for giant nevi removal?

There are several different plastic surgery techniques used to remove moles of different sizes. Giant nevi are typically approached in one of three ways: serial excision, excision and grafting, and tissue expansion. Dr Ricardo will discuss the potential surgery options with you to help determine which techniques will provide the best potential surgical process and outcomes.

Serial excision involves the removal of one portion of the lesion with primary closure of the wound followed by a similar additional surgery or surgeries to remove the remaining lesion. Between each surgical stage, the patient will be allowed to heal and the scars and tissues start to soften and/or stretch to allow for re-excision without too much tension on the repaired incision.

Excision and grafting involve the removal of most or all of the lesions and closure of the skin defect with a skin graft from the patient or with skin substitutes. This technique allows for rapid removal of the abnormal tissue with fewer surgeries at the expense of cosmetic wound closure. Skin grafts can leave more significant scarring and may prolong postoperative recovery time.

Tissue expansion is a technique invented to grow additional skin that can then be used as a skin flap or full-thickness skin graft. During tissue expansion, one or more silicone balloons are placed under the skin and then subsequently inflated with water over several weeks until the desired growth of skin is reached. By expanding available normal skin adjacent to the nevus, part or all of the nevus can ultimately be removed, and then the extra skin used to replace the missing tissue and close the defect. Depending on the size of the lesion this process may need to be repeated to achieve near or complete removal of the lesion.

Sometimes these techniques are used together to treat this problem. For instance, a large lesion may first be serially excised to make it smaller until the skin is too tight to allow further excision at which point removal and grafting or tissue expansion and flap closure may be considered to complete the process.

What are the steps of a giant nevi removal procedure?

Step 1 – Anaesthesia
Medications are administered for your comfort during the surgical procedure. The choices include intravenous sedation and general anaesthesia. Dr Ricardo will recommend the best choice for you.

Step 2 – Surgical procedure
The removal of a giant congenital nevus requires incisions around the edge of the visible lesion, including a small rim of normal tissue to help ensure complete removal. The involved skin will be removed full-thickness through the skin and into the subcutaneous tissues. The lesion will be sent for pathology review to ensure the lesion was benign at the time of excision. If a serial excision is planned, often the central portion of the lesion is removed initially followed by the edges at a later date.

Step 3 – Closing the incisions
Nevus excisions can be closed with removable or absorbable sutures or staples. Typically several different layers of stitches will be used so only a portion of them may be visible at the end of the surgery, while the rest are hidden beneath the skin. The incision sites will be covered at the end with glue and/or tapes or bandages. Elastic wraps or a splint may be used as needed to further protect the incision sites.

Step 4 – See the results
Surgery to remove a congenital nevus will ultimately result in a normal or near-normal contour area without the presence of a large brown lesion. Over time the associated scars will fade. Based on preoperative planning, scars should be placed in such a way as to promote normal growth and function of the involved area.

What should I expect during my giant nevi removal recovery?

Following surgery to remove a congenital nevus, gauze dressings or other types of bandages may be applied to the incisions. An elastic bandage or immobilizer may be used to help minimize swelling and prevent excessive movement at the surgery site during the healing process. Post-surgical discomfort can be controlled with pain medication. After surgery, diligent sun protection is essential to prevent the formation of irregular scars.

You will be given specific instructions on how to care for the surgical site, medications to apply or take orally to aid healing and reduce the potential for infection, specific concerns to look for at the surgical site or in your general health, and when to follow up with Dr Ricardo. Remember to always follow his instructions to ensure the success of your surgery.

Depending on the surgical technique used, sutures may need to be removed from the skin following surgery. Healing will continue for several weeks as swelling resolves. Incision site scars will mature and fade over many months. The surgical incisions mustn't be subjected to excessive force, abrasion, or motion during the time of healing.

What results should I expect after my giant nevi removal?

Depending on the number of surgeries required to completely remove the lesion, the final results of surgery may not be apparent for some time, until all of the procedures have been completed. In general, things will look better in a step-wise fashion if the nevus is removed in stages. If tissue expansion is used, the area may look very abnormal while the balloons are inflated, but this typically lasts only for a short period. During this time, activities may need to be restricted or clothing altered to accommodate the expanded balloons and tissue.

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