Giant congenital nevi: A 20-year experience and an algorithm for their management

A variety of treatment options exists for the management of giant congenita l nevi. Confusion over appropriate management is compounded because not all giant congenital nevi are pigmented, and malignant potential varies betwee n different types. The present study sought to define factors in the presen tation of giant congenital nevi that could provide an algorithm for their m anagement, with respect to both the extent of resection and subsequent reco nstructive options. A retrospective review of all patients who presented with a congenital nevu s of 20 cm(2) or greater since 1980 was performed, distinguishing among nev i involving the head and neck, the torso, and the extremities. Sixty-one pa tients 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 pa tients) and nevus sebaceus (four patients). Those not having malignant pote ntial were verrucous epidermal nevi (three patients) and a woolly hair nevu s (one patient). Of the 60 giant congenital nevi operated on, expanded flap s were used in 25, expanded full-thickness skin grafts were used in 10, spl it-thickness or nonexpanded full-thickness skin grafts were used in 13, and serial excision was used in 30. After 1989, operations tended to use multi modality treatment plans, with an increased use of expanded full-thickness grafts and immediate serial tissue expansion. The use of serial excision, p articularly 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 excisio n 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. Seria l excision was the most common form of treatment in the extremities, used i n 50 percent of procedures. Tissue expansion in the extremities was infrequ ently used to provide an expanded flap (8 percent of procedures), whereas i t was frequently used to provide expanded full-thickness skin grafts harves ted from the torso (used in 31 percent of procedures). On the basis of these data, algorithms for the extent of resection and subs equent reconstructive options for giant congenital nevi were developed. The ir management should be formulated relative to pigmentation, malignant pote ntial, and anatomic location of the respective lesions.