NEW YORK Plastic surgeons' approach to nevi in challenging anatomical locations may differ from that of dermatologists, said Dr. Barry Zide at a dermatology conference sponsored by New York University.
"When I look at nevi, I have questions that have to be asked: Can it be shaved? What residual or abnormal pigment will occur, and why? How many aesthetic units are involved? What ancillary methods can be used? How many steps will it take?" said Dr. Zide, professor of plastic surgery at New York University, New York.
One thing to avoid is scab formation after shaving. This can be prevented by not allowing the shaved area to dry out. "Patients have to keep [an adhesive bandage] on for 710 days postop," Dr. Zide said.
"A bulky nevus of the nose has a minimal tendency to be malignant, so you can leave some nevus without taking the whole thing off," said Dr. Zide, referring to a case in which he did not have to biopsy the whole lesion but worked with shaving, abrasion, and electrolysis to manage the lesion. The advantage to this approach is that it leaves no reconstructive defect.
For dark lesions located above the tip of the nose, skin grafting is an option. "It is important to think in terms of aesthetic units," he said, adding, "The best place for a graft of the nose is the forehead. It has good color." A patch and edges are not perfect, so sanding the units post dermabrasion over a wide area that is not just limited to the actual skin graft is important. "Think big on dermabrasion, even though the graft can be small."
When confronted with a big nevus in a very young child, remember that in babies younger than 4 months old, there is a lot of skin to work with because their skin on the head hasn't yet firmly bound to the scalp. "You can take a lot of skin and do a straight excision in some cases, or a W-plasty," Dr. Zide explained.
Sometimes multiple steps are needed. Patients should always be informed of and prepared for the biopsy of a nevus to entail several steps.