A Facelift for a Two-Year-Old: Alternative Use of Facelift Approach, to Achieve Serial Excision of a Medium Sized Congenital Naevus, in a Two-Year-Old Patient

doi:10.4236/ss.2011.29099

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Surgical Science, 2011, 2, 453-455

doi:10.4236/ss.2011.29099 Published Online November 2011 (http://www.SciRP.org/journal/ss)

A Facelift for a Two-Year-Old: Alternative Use of Facelift

Approach, to Achieve Serial Excision of a Medium Sized

Congenital Naevus, in a Two-Year-Old Patient

Marco Malahias, Diaa Othman, George Spyrou

Plastic Surgery Department, Pinderfields Hospital, Wakefield, UK

E-mail: [email protected]

Received June 30, 201 1; revised September 22, 2011; acce pted October 29, 2011

Abstract

Historically, face-lifting consisted of elevating the skin, placing it under tension to reduce the wrinkles, re-

secting the skin needed to accomplish this, and then securing the resected edges. However, over time, facelift

surgery evolved beyond the Dorland’s definition of “rhytidectomy” (excision of skin for the elimination of

wrinkles [1]) and various different techniques and indications have been described. We report of the pre-

auricular facelift approach, as described by Skoog [2] for alternative use: The excision of a giant cell tumour,

utilizing this facelift technique to achieve serial excision from a two year old, male patient’s face. This has

resulted in a satisfactory aesthetic outcome and scar alignment in favourable area as well as excision of a

significant part of the lesion, and awaiting further serial excision for completion.

Keywords: Facelift, Congenital Naevus, Facial Reconstruction

1. Purpose

A two-year-old male patient was born with a giant naevus

involving most of the left side of his face (Figure 1). The

lesion had increased both in size and pigmentation as he

grew older, which prompted the parents to seek medical

advice, resulting in their referral to our unit. The lesion’s

diameter measured (6 cm × 7.5 cm). The main concern

with this patient was the potential risk of malignant

transformation and the overall cosmetic appearance of

this young child, which may have led to him being bul-

lied by his peers, once he reached school age.

2. Method

Several management options where considered including

Laser therapy, dermabrasion and excision followed by

sheet grafting, tissue expansion and serial excision. Both

dermabrasion and laser therapy where not feasible, due to

the lack penetration to deeper tissues. Excision and sheet

grafting was an unacceptable solution for the parents, who

rejected the idea of visible scars in their son’s face.

The idea of tissue expansion was abandoned, due to

the lack of sufficient, unaffected tissue between the angle

of the mouth and the most anterior border of the pig-

mented area. Therefore, after meticulous planning and in

depth discussions with the parents, we decided on the

option of serial excision of the lesion and chose the pre-

auricular facelift approach, traditionally associated with

rhytidectomy in older patients usually beyond their fifth

decade of life.

The skin of the left side of the face was incised via a

standard pre-auricular approach; a single dose of intra-

venous antibiotic (cefuroxime) was administered at in-

duction. The skin with the overlying giant naevus was

dissected mobilised and elevated (Figure 2). The intra

operative findings included: 1) abnormally pigmented-

skin, which was of variable thickness, resulting in areas

that were easily perforated by the instruments routinely

utilized for skin retraction; 2) subcutaneous fat atrophy;

3) an increase in tissue elasticity al lowing easy stretch of

the pigmented skin to achieve maximal ex cision, without

distorting the angle of the mouth or altering the position

of the ala of the nose.

3. Result

During the first of a total of three planned procedures

40% of the initial lesion was excised (Figures 3 and 4).

Skin closure, without excessive tension was achieved

454 M. MALAHIAS ET AL.

Figure 1. Preoperative lesion.

Figure 2. Intraoperative dissection.

Figure 3. Immediate postoperat i ve closure.

Figure 4. Immediate postoperative closure with area excised.

and a small suction drain was placed in situ for 24 hours,

to collect any excessive ooze from the wound. The sub-

sequent stages where planned six to nine months apart.

4. Discussion

Congenital nevi are present at birth and result from a

proliferation of benign melanocytes in the dermis, epi-

dermis, or both. Occasionally, nevi that are not present at

birth but are histologically identical to congenital nevi

may develop during the first two years of life. This is

referred to as congenital nevus tardive [1].

The aetiology from the congenital melanocytic naevi

remains unclear. The melanocytes of the skin originate in

the neuroectoderm, although the specific cell type from

which they deriv e remains unknown [2-4 ].

Congenital nevi have been stratified into 3 groups ac-

cording to size. Small nevi are less than 1.5 cm in great-

est diameter, medium nevi are 1.5 - 19.9 cm in greatest

diameter, and large or giant nevi are greater than 20 cm

in greatest diameter. Giant nevi are often surrounded by

several smaller satellite nevi. For giant congenital mela-

nocytic nevi, the risk of developing melanoma has been

reported to be as high as 5% - 7% by age 60 years [5,6].

Because of the increased risk of melanoma associated

with congenital nevi, attempts have been made to distin-

guish congenital nevi from acquired nevi on the basis of

histology. Distinguishing histologic features include: 1)

involvement by nevus cells of deep dermal appendages

and neurovascular structures (including hair follicles,

sebaceous glands, arrector pili muscles, and within blood

vessels walls); 2) extension of nevus cells to deep dermis

and subcutaneous fat; 3) infiltration of nevus cells be-

tween collagen bundles; and 4) a nevus cell-poor sub

epidermal zone [7-9].

5. Conclusions

Surgical removal of congenital melanocytic nevi is per-

formed for two main reasons, first, to improve the cos-

metic appearance of the patient and second , to reduce the

likelihood of malignant transformation. The use of a

facelift approach to solve this predicament shows how

versatile surgical skills need to be, in order to find an

answer to any operative challenge.

6. References

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[3] O. J. Clemmensen and S. Kroon, “The Histology of ‘Con-

genital Features’ in Early Acquired Melanocytic Nevi,”

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