Large Nevus (Mole)

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moleA large pigmented mole or melanocytic nevus may appear on the face or body of a child.  The concerns of having a large nevus on the face or body is both the unsightly appearance of the nevus and the slightly increased potential of the nevus changing into a skin cancer.

A large or giant melanocytic nevus can only be removed with surgery.  There is no lotion or medicine to treat the mole and make it disappear.  Laser treatment seemed promising at first but has not advanced over the last decade to offer a replacement solution to surgical removal.

Surgical treatment for large moles may seem simple to both the medical and plastic surgery communities.  However, I believe it is one of the most difficult and challenging problems to treat surgically.  I have seen the most distorted faces from other plastic surgeons’ surgical treatment of children with a large mole to the face.  Why?  The reasons are several.  First, a plastic surgeon may believe that he or she can take care of the problem.  Second, a plastic surgeon may believe that he or she can remove the entire large mole with one, two or three operations (known as staged excision if more than one operation).  Third, a surgeon does not believe that he or she will make things worse.

Let’s consider an operation to excise a one inch in diameter round melanocytic nevus (mole) on the face. When we consider how much skin and soft tissue a surgeon can remove without creating a distortion of the face, we have to consider where the mole is located.  If the mole is near the jawline, lateral on the face and away from the lip, nose and lower eyelid, a serial excision may result in a decent outcome, without creating any distortion of the lip or the nose or the lower eyelid.

However, if the one inch in diameter pigmented mole is near the upper lip, nose or lower eyelid, the chances of distorting the upper lip, nose or lower eyelid is much, much higher.  A serial surgical excision, no matter how many operations are performed, may lead to a significant distortion of the upper lip, lower eyelid or the nose.  Is this a good trade?

The treatment options for large moles to the face are not many.  They include surgical excision with direct closure (as mentioned above), use of tissue expanders, and skin grafting.

Use of tissue expanders is a three step technique: 1) the first step is to insert the tissue expander; 2) the second part is to inflate the tissue expander weekly in the office, which may take a few months; 3) the third step is to remove the tissue expander, excise the pigmented mole, and use of the expanded skin to reconstruct the area of mole excision.

Skin grafting is performed in one operation.  The large mole is excised and a full thickness skin graft is used to resurface the skin defect.  A split (partial) thickness skin graft should never be used.  A full thickness skin graft obtained from behind the ear or the uppermost part of the chest (above the collar bone) will give the best color match to resurface skin on the face.  If the surface area of skin needed for skin grafting prevents direct closure of the wound on the back of the ear, a skin graft from the lower abdomen is used to resurface the back of the ear in order to not distort the ear.

As I have pointed out, surgical treatment of a large mole on the face is not easy.  The goals of any surgical treatment plan are to remove the mole entirely, create a really good scar, and not distort important structures of the face, such as the lip, nose, eyelid and brow hair line.   However, if trying to excise the large mole entirely with direct closure will lead to a distortion of the lip, nose, eyelid or brow hairline, then this surgical plan should not be considered.  Skin grafting or a tissue expansion technique would be the better strategy.  This is why I think the idea of The Natural Look is an important guiding surgical principle.

Experience counts in navigating through these important options in treating a large mole.  It is important to understand the risks and benefits of the different surgical options from a pediatric plastic surgeon with many years of experience treating large moles.