Mole Removal Causes Pediatric Patient To Suffer Facial Necrosis

This case involves a boy born with a mole on his nose and had spacers surgically placed to add extra skin. At age 5, the boy’s parents chose to have the mark removed with the understanding that the skin was approximated to cover the defect. The boy had a number of complications following the surgery including necrosis of the tissue covering his nose. He went through a number of follow up surgeries to remedy his disfigurement and make sure his nasal passages were patent, among other concerns. In spite of the additional surgeries, the boy has severe scarring on his face.

Question(s) For Expert Witness

1. What is your experience performing procedures like the one described?

2. What are the treatment options for a disfiguring nevus?

3. When can a nevus be left alone and when is it necessary to operate, if ever?

Expert Witness Response E-156861

I am a pediatric plastic and craniofacial surgeon. My practice consists of a majority of pediatric cases, many of which are nevus and soft tissue lesion cases. I have been in practice for 7 years, 2 years in academics and 5 years in hospital-based practice. I am currently the medical director of a children's hospital cleft lip and palate team. My practice consists of approximately 75% pediatric patients and 25% adult patients. I excise pigmented nevi and other soft tissue lesions over 100 times per year. I remove larger nevi requiring serial excision perhaps 5-6 times per year. The largest nevi that require tissue expanders to recruit skin prior to excision are rarer, and I do perhaps only 2-3 per year. I do, however, have extensive, frequent experience with using tissue expanders for a variety of other reasons, such as breast reconstruction. The principles and practices of tissue expansion are the same, regardless of the reason for using them or the location.

Large, pigmented nevi historically were thought to have a very high rate of transformation to malignant melanoma. We know now that the risk is very low, likely low single digit percent. Therefore, the potential cancer risk needs to be weighed carefully against the potential for disfigurement and scarring from excision, especially in cosmetically sensitive areas such as the face. It is my practice to have a candid discussion with the family about the possible outcome with excision with its resultant scarring versus the psychosocial consequences and cancer risk associated with choosing not to remove it. There may not be a right or wrong answer regarding the need to excise these types of nevi, assuming there is no concern for malignancy at the time of evaluation. Many parents, however, choose excision due to their worry about appearance if the lesion is left alone. Reasons to definitely operate include biopsy-proven cancer or atypia, ulceration, infection, or severe psychosocial problems due to appearance.