Artificial Skin in the Treatment of a Large Congenital Nevus
An 8-year-old girl had a large congenital nevus involving the posterior thigh, leg, and foot. The nevus on non-weight-bearing areas was resected, and the areas were resurfaced with artificial skin and ultra-thin split-thickness grafts. A good result was ultimately achieved. Our management of this case and the relative merits of this new technology are detailed.

Management of giant congenital nevi has historically been challenging. Frequently, resection of these large melanocytic lesions produces extensive defects, which have usually been managed with split-thickness skin grafts, muscle flaps or fasciocutaneous flaps if the resultant defect is not too large. Conventional split-thickness grafts of 12 to 15 thousandths of an inch thickness will leave some donor site morbidity with hypopigmentation over time, and the recipient site will contract to various degrees, depending on graft take and thickness. Conventional flap procedures always leave significant donor site scars and potential dysfunction if used for large surface area requirements. Harvest of a latissimus flap creates some flattening of the thorax that is permanent, even if harvested with endoscopic assistance. Scars are also produced with tissue expander approaches.

Giant congenital nevi are fortunately uncommon and have been arbitrarily defined by size (lesion greater than 20 cm diameter), or as a lesion that occupies a region considered major such as the face, or as a lesion that cannot be excised without significant deformity resulting. While aesthetic considerations are important, the prime reason for excision of giant congenital nevi is the risk for subsequent malignant transformation into malignant melanoma. The potential for melanomatous transformation of a giant nevus has been variously reported and ranges from 2% to 42%. Clinically, decisions regarding surgical resection have been based on the premise that many giant nevi will not transform into melanoma and thus many patients have been expectantly observed for years. Problematically, when melanoma develops in childhood the prognosis is extremely poor, especially in cases of melanoma manifested in a giant nevus. Death from widespread disease is the usual outcome in these cases.

Evidently, the reluctance of surgeons to resect giant nevi is due to the potential for scarring and dysfunction that could occur after resection. This reluctance is understandable from our learned experiences over time with skin grafts and flaps. It is evident that a better way should exist to treat these problems. Lessons learned from treating burns of large body surface areas may apply to the treatment of giant nevi when large areas of skin have to be resected to remove the nevus and prevent the potential for malignant transformation.

Since its development by Burke et al, artificial skin has been used with good success in burns. Logically, it should follow that artificial skin could be used for other subgroups of patients who may require coverage of large body surface areas. Advantages cited for artificial skin include less donor and recipient site pain, improved cosmesis of donor and recipient sites, less risk for infection because the wounds are closed, and improved function of the treated areas because of less hypertrophic scarring. Potential disadvantages of artificial skin are expense, second surgery for grafting, and infection with loss of the artificial skin. We report a case in which artificial skin (Integra, Integra Lifesciences Corp) was used to resurface areas from which a giant congenital nevus was resected.