Received: 26 November 2019 | Revised: 24 March 2020 | Accepted: 26 March 2020

DOI: 10.1111/jocd.13416

ORIGINAL CONTRIBUTION

Two-stage surgical treatment of giant congenital melanocytic

nevus around the auricle

Weiwei Dong MD | Yupeng Song MD | Haiyue Jiang MD | Bo Pan MD |

Leren He MD | Qinghua Yang MD

Department of Auricular Reconstruction,

Plastic Surgery Hospital, Chinese Academy Abstract
of Medical Sciences and Peking Union Background: This study presents the results of complete excision of giant congenital
Medical College, Beijing, China
melanocytic nevi (GCMN) on the auricle, forehead, or periorbital area combined with
Correspondence tissue expansion, and skin graft transplantation performed in two stages based on
Qinghua Yang, Department of Auricular
Reconstruction, Plastic Surgery Hospital, 10 years of experience.
Badachu Road, Shijingshan District, Beijing, Aims: To solve the giant congenital melanocytic nevi on the auricle, forehead, or peri-
China.
Email: [email protected] orbital area with two-stage operation.
Patients/Methods: A total of 21 patients with GCMN were included in this study.
The operation combined tissue expander and skin graft transplantation.
Result: All GCMNs were successfully and completely excised. No patient in the study
group had experienced skin contraction or auricular deformation at 3 years after
treatment.
Conclusion: Two-stage operation is effective for removing GCMN on the auricle or
face and can achieve good oncological and cosmetic results.

KEYWORDS

giant congenital melanocytic nevi, skin graft, tissue expansion

1 | I NTRO D U C TI O N In this study, we performed a two-stage surgery to resolve

GCMN. We believe that these patients would benefit from the
Giant congenital melanocytic nevi (GCMN) generally have an area shorter period and lower cost associated with this protocol.
larger than 20 cm2, are associated with a hair-like or verrucous tex-
ture, and are often accompanied by satellite lesions.1 GCMN not only
affect the appearance of the patient but also carry certain risks. For 2 | M ATE R I A L S A N D M E TH O DS
example, when located on the head, the potential risk of extension
into the pia mater increases. Neurological manifestations including 2.1 | Clinical data
epilepsy can occur when the GCMN involves the spine; GCMN on
the spine can also be associated with spina bifida or meningocele From 2007 to 2017, a total of 21 patients (twelve male and nine fe-
with pneumocele, and when it involves nerve fibers, GCMN are as- male) aged 2-30 years old presented with congenital giant nevi and
sociated with a cancer risk. In addition, postnatal giant nevi increase are described here. The average age of the patients is 10.6. These
in size in proportion to body size, with 5%-10% of such nevi develop- giant nevi involved the auricle, face, and scalp. The area of the black
2
ing into melanoma with a poor prognosis. For these reasons, giant nevi was 5 cm × 6 cm to 13 cm × 15 cm. Enrolled patients have done
melanocytic nevi should be excised as soon as possible after detec- preoperative examinations before surgery, and brain MRI was per-
tion. The currently available typical treatments include skin grafts, formed and examined by neurologists to excluded neurocutaneous
flaps, tissue expanders, and laser treatments.3,4 melanosis, no surgical contraindications (Table 1).

J Cosmet Dermatol. 2020;00:1–8. wileyonlinelibrary.com/journal/jocd© 2020 Wiley Periodicals, Inc. | 1

2 | DONG et al.

TA B L E 1 All 21 patients' photographs

Number Patient ID Gender Photograph 1 Photograph 2

1 102106 Female

2 098451 Female

3 101459 Female

4 119561 Male

5 091225 Male

6 080055 Male

(Continues)
DONG et al. | 3

TA B L E 1 (Continued)

Number Patient ID Gender Photograph 1 Photograph 2

7 111099 Female

8 117743 Female

9 112747 Male

10 112764 Female

11 086954 Male

12 071097 Male

(Continues)
4 | DONG et al.

TA B L E 1 (Continued)

Number Patient ID Gender Photograph 1 Photograph 2

13 112873 Male

14 125986 Male

15 108112 Male

16 111099 Female

17 112020 Male

18 048942 Male

(Continues)
DONG et al. | 5

TA B L E 1 (Continued)

Number Patient ID Gender Photograph 1 Photograph 2

19 101036 Male

20 112531 Female

21 094563 Female

2.2 | Surgical approach the perichondrium, 1/400 000 units of adrenaline saline was injected
into the lesion before surgery. The lesions on the anterolateral side of
We divided the operation into two stages. In the first stage, while the auricle were completely removed from the perichondrial surface,
the dilator was embedded in the normal skin around the auricle, the and sectional skin grafts were cut from the groin region according to
lesions behind the ear were removed. At the same time, the skin was the size of the lesions. The donor sites were wrapped with soft surgi-
removed from the abdomen and the skin graft was implanted behind cal dressing. Pathological tissue was removed and sent for pathological
the ear. In the second stage, the dilator was removed, resects the examination.
nevi and repair of lesions with expanded skin flaps. Postoperative hematoma and the drainage tube were checked.
The drainage tube was removed when the color of the drainage fluid
turned clear. After the stitches were removed, the tissue expander
2.2.1 | First-stage operation was injected with normal saline twice per week. The volume of saline
was based on the color or texture of the skin. During the process of
An appropriate tissue expander and its placement were selected based tissue expander injection, the blood supply and color of the flap were
on the size of the nevi. The length of the tissue expander should be 2 cm closely observed, and the reflex of capillary refill was checked. When
exceed to the length of the nevi being excised. The patient was placed the thickness of the expanded flap and the expanded skin volume
under general anesthesia with tracheal intubation. To obtain as much had reached the required levels, water injection should be discontin-
expanded skin as possible, we implanted expanders in the face, the pos- ued for 1 month to reduce the retraction rate of the expanded flap.
terior auricular mastoid region, and the forehead. In the operative area,
the scope of the embedded expander was marked with methylene blue.
The area being expanded was subcutaneously stripped, and electro- 2.2.2 | Second-stage operation
coagulation hemostasis was performed after the placement of the ex-
pander and injection port. After saline was injected, while the drainage The second-stage surgery included the removal of the lesion be-
tube was placed, the connection of the injection port was checked to hind and around the auricle, the removal of the tissue expander,
ensure that there was no bending. The remaining tissue expanders were and the transfer of the expanded flap. Before the operation, the tis-
embedded with the same method. To assist in separating the skin from sue expander and its envelope were removed. The tissue expander
6 | DONG et al.

F I G U R E 1 A-D, Preoperative
photographs, E-G, Preoperative
photographs of the second operation,
H-K, Postoperative photographs, and L,
Postoperative photographs at 1 year after
surgery

was injected with anesthetic solution (lidocaine 10 mg + adrenaline 1-year follow-up showed that no obvious shrinkage of the skin or
0.1 mg + normal saline 80 mL). The surface envelope and the ex- distortion of the auricle had occurred. There was no recurrence at
panded flap were transferred to the lesion resection area as far as pos- 1 year following the second operation, and no obvious contracture
sible to suture the incision within the hairline. If there was no healthy was observed in any of the expanded flaps. Thus far, one follow-up
skin remaining behind the ear, a sectional skin graft was cut from the patient has developed severe scar hyperplasia and will be described
contralateral groin and planted on the wound behind the auricle. in the following case 1.
Surgeons took care to preserve the integrity of the perichon-
drium during the operation because the destruction of the perichon-
drium makes the survival of the grafted skin on the cartilage surface 3 | R E S U LT S
problematic.
3.1 | Case 1

2.3 | Surgery results A 5-year-old male was admitted to the hospital for congenital
nevis of the left auricle and pigmentation of the head and face.
Satisfactory results were obtained in all 21 patients. No complica- Melanin on the left auricle and head and neck was found at birth.
tions, such as tissue expander leakage, angulation, and blood flow The nevi's size was approximately 13.0 cm × 11.5 cm. The bound-
obstruction, were experienced during expansion. The main compli- ary was unclear, and the surface was rough with hair growth.
cation was poor skin grafting, delayed healing as a result of dressing Patient has provided informed consent for publication of the case
changes, scarring, and effects on the shape of the outer auricle. A (Figure 1A-D).
DONG et al. | 7

In the second-stage surgery (Figure 1H-K), the patient under-

went nevi resection, tissue expander removal, expanded flap trans-
fer and repair, and abdominal skin removal. The total expansion
volume of the tissue expander in the head, neck, and facial was 576,
389, and 156 mL. The excision size of nevi depended on the size of
the expanded flaps. Leave the incision along the hairline and recon-
struct the sideburn was notable in this surgery.
After 1 year of follow-up, the patient developed severe scar hy-
perplasia (Figure 1L), and he recently returned to our hospital for
triamcinolone acetonide injection for scar treatment. The scar did
not affect the shape of the auricle.

3.2 | Case 2

A 22-year-old male was admitted to the hospital with a congeni-

tal left ear nevi present from birth. After birth, melanin nevi were
found in the left auricle, the anterior auricle, the posterior auricu-
lar mastoid region, and the ipsilateral head and neck (Figure 2A-C).
The border was not clear, the melanin volume gradually increased
with age, and some of the nevi surface showed hair over an ap-
proximately 18 cm × 12 cm area. The patient underwent partial
excision of the pigmented nevi of the left auricle, skin grafting with
moderate thickness, and expansion of the face, head, and neck
(Figure 2D-F). In the second-stage surgery, the patient underwent
nevi resection, tissue expander removal, expanded flap transfer
and repair, abdominal skin removal, and mid-thickness skin graft-
F I G U R E 2 A-C, Preoperative photographs, D-F, Preoperative
ing (Figure 2G-I). The operative method was the same as that used
photographs of the second operation, and G-I, Postoperative
in case 1. Patient has provided informed consent for publication
photographs
of the case.

The patient underwent head, face, and neck tissue expander

placement under general anesthesia, partial removal of the auric- 4 | D I S CU S S I O N
ular nevi, skin removal, and skin grafting in the first-stage operation
(Figure 1E-G). The surgical incision was made on the head, face, and It is worth noting that giant nevi of the auricle cannot be removed
neck of the patient, and the area in front of the left ear and behind the in only one operation because the substructure of the auricle is too
ear and neck was stripped. After infiltration with local anesthetic, a complex. The main blood supply to the front auricle is the superficial
facial tissue expander was inserted within the marked stripping area, temporal artery, and the posterior auricular artery is located behind
and the skin was incised consistent with the preoperative design. A the auricle. A one-stage operation cannot guarantee the blood sup-
slightly larger cavity than the base of the tissue expander was formed, ply to the skin grafting area and therefore associated with a higher
resulting in an incision approximately 3 cm in length. After complete risk of skin necrosis, adverse skin graft survival, and even infection
hemostasis was induced by electrocoagulation, 100 mL tissue expand- or necrosis of the auricle cartilage. The unique nature of congeni-
ers were placed in the corresponding cavity. A 400 mL tissue expander tal giant nevi of the auricle results in a condition that is clinically
was placed on the deep side of the cap-shaped aponeurosis of the complicated to diagnose and treat. It is specific in nature in the fol-
head, a 300 mL tissue expander was placed on the superficial side of lowing multiple ways: (a) The anatomical structure of the auricle is
the platysma muscle, and a drainage tube was placed behind the ear. complex, and its substructure is one of the most complicated regions
The area of the resected nevi was approximately 10 cm × 6 cm. in humans. During the process of excision, special attention must
Subcutaneous tissue was removed on the surface of the deep fascia. be paid to the depth and not only to the complete removal of the
The skin was incised along the incision line to the normal subcutane- nevi. Blood supply in the cartilage must be retained to avoid involve-
ous tissue level, and the pigmented nevi in front of the auricle were ment of the auricle structure. The blood supply of the auricle comes
removed on the perichondral surface. The skin was incised along the mainly from the anterior auricular branch of the superficial temporal
designed incision to the normal subcutaneous tissue level, and the artery and the posterior auricular artery.5 A clear vascular network
nevi were removed from the designed level. can be seen beyond the perichondrium. This is the foundation of skin
8 | DONG et al.

graft survival.6 (b) After the auricle nevi is removed, the lesion on the or earlobe molding can be performed 1 year following the second
skin remains large and is difficult to fully address with a single tissue operation.9
expander. We proceeded with a two-stage operation to protect the
blood supply of the auricle, and this approach resulted in a faster AC K N OW L E D G M E N T
recovery while also improving the economic cost of treatment and This research was not supported by any specific grant from funding
shortening the total duration of recovery compared to an approach agencies in the public, commercial, or not-for-profit sectors.
that requires multiple embeddings of the expander. (c) The area of
giant nevi, excluding the auricle, often extends to the postauricular
mastoid region or even to the scalp. Thus, the subdivision and con- ORCID
sequential duration of the operation are critical, making the surgical Qinghua Yang https://orcid.org/0000-0002-2013-5741
plan complex. (d) Giant nevi of the auricle sometimes involve the ear
lobe. When completely removing the nevi, it is difficult to preserve REFERENCES
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full-thickness infiltration treated with a single-surgery approach, He L, Yang Q. Two-stage surgical treatment of giant
the earlobe often cannot be retained. After two-stage surgery, the congenital melanocytic nevus around the auricle. J Cosmet
thickness and size of the affected earlobe will be significantly smaller Dermatol. 2020;00:1–8. https://doi.org/10.1111/jocd.13416
than those of the healthy earlobe. To achieve symmetry, fat filling