Giant Congenital Nevi: A 20-Year Experience and an Algorithm for Their Management

Transcription

1 Giant Congenital Nevi: A 20-Year Experience and an Algorithm for Their Management Arun K. Gosain, M.D., Timothy D. Santoro, M.D., David L. Larson, M.D., and Reudi P. Gingrass, M.D. Milwaukee, Wis. A variety of treatment options exists for the management of giant congenital nevi. Confusion over appropriate management is compounded because not all giant congenital nevi are pigmented, and malignant potential varies between different types. The present study sought to define factors in the presentation of giant congenital nevi that could provide an algorithm for their management, with respect to both the extent of resection and subsequent reconstructive options. A retrospective review of all patients who presented with a congenital nevus of 20 cm 2 or greater since 1980 was performed, distinguishing among nevi involving the head and neck, the torso, and the extremities. Sixty-one patients with giant congenital nevi were evaluated (newborn to age 16 years), of which 60 nevi in 55 patients have been operated on. Giant congenital nevi having malignant potential were pigmented nevi (53 patients) and nevus sebaceus (four patients). Those not having malignant potential were verrucous epidermal nevi (three patients) and a woolly hair nevus (one patient). Of the 60 giant congenital nevi operated on, expanded flaps were used in 25, expanded full-thickness skin grafts were used in 10, split-thickness or nonexpanded full-thickness skin grafts were used in 13, and serial excision was used in 30. After 1989, operations tended to use multimodality treatment plans, with an increased use of expanded full-thickness grafts and immediate serial tissue expansion. The use of serial excision, particularly in the extremities, also increased after Serial excision was the treatment of choice when it could be completed in two procedures or less, which occurred in more than 80 percent of cases using serial excision alone. Expanded flaps were the most common mode of reconstruction in the head and neck region and were used in 49 percent of these procedures. Serial excision was the most common form of treatment in the extremities, used in 50 percent of procedures. Tissue expansion in the extremities was infrequently used to provide an expanded flap (8 percent of procedures), whereas it was frequently used to provide expanded full-thickness skin grafts harvested from the torso (used in 31 percent of procedures). On the basis of these data, algorithms for the extent of resection and subsequent reconstructive options for giant congenital nevi were developed. Their management should be formulated relative to pigmentation, malignant potential, and anatomic location of the respective lesions. (Plast. Reconstr. Surg. 108: 622, 2001.) The optimal management of giant congenital nevi has been a longstanding surgical challenge, both because of differences pertaining to the unique biologic characteristics belonging to the different types of nevi and because of the reconstructive complexity. Arbitrary size criteria defining pigmented giant congenital nevi include those greater than 2 percent body surface area, 1 nevi greater than 20 cm in largest diameter, 2 and nevi that cannot be excised in a single procedure. 3 We chose to study lesions greater than 20 cm 2 in size. Because there is considerable overlap in reconstructive principles after resection of both pigmented and nonpigmented giant congenital nevi, our surgical experience for all forms of the lesion is combined to develop a more consistent and clinically useful algorithm. Because the potential for malignant transformation exists within pigmented giant congenital nevi, 1 surgical excision remains the standard of care for their treatment. Dermabrasion has been used in the treatment of these lesions 4 ; however, this technique may not remove the majority of nevus cells and is not currently recommended as an effective treatment for the prevention of potential malignant transformation. 5 Although laser therapy has also been used to treat congenital pigmented nevi 6 and may be useful in lightening unresectable lesions, the number of nevus cells actually removed by this technique cannot be docu- From the Department of Plastic and Reconstructive Surgery, Medical College of Wisconsin. Received for publication February 7, 2000; revised October 20, Presented at the 78th Annual Meeting of the American Association of Plastic Surgeons, in Colorado Springs, Colorado, May 4,

2 Vol. 108, No. 3 / MANAGEMENT OF GIANT CONGENITAL NEVI 623 mented. For this reason, the present study will focus only on surgical excision of giant congenital nevi, because this is the only technique in which complete removal of nevus cells can be documented. The purpose of the present study is to address the following questions: (1) What are the reasons to operate on pigmented and nonpigmented lesions, and how extensive a resection should be performed for each presentation of a giant congenital nevus? (2) What reconstructive options should be used after resection of a giant congenital nevus, and when is it appropriate to combine different reconstructive modalities? (3) Do the optimal reconstructive options vary in different anatomic regions of the body? METHODS A 20-year retrospective review was performed for all giant congenital nevi evaluated at the Medical College of Wisconsin from January of 1980 through May of Giant congenital nevi were defined as all nevi with a surface area greater than 20 cm 2. A separate assessment was made for the head and neck, torso, and extremities. Lesions of the head and neck consisted of all lesions above the clavicles. Lesions of the torso consisted of all lesions involving the chest, abdomen, back, and buttocks. Lesions of the extremities consisted of all lesions distal to the axilla in the upper extremities or distal to the groin in the lower extremities. Single lesions extending into more than one of the above-defined regions were classified as distinct nevi, provided the component within the given region was greater than 20 cm 2.A nevus extending from the back to the arms that involved greater than 20 cm 2 in each of the two body zones was classified as two giant congenital nevi for the purpose of this study. Although multiple satellite nevi were present in several patients, the index lesion was still required to be greater than 20 cm 2 to be considered a giant congenital nevus. RESULTS Of the 61 patients who were evaluated, 60 nevi in 55 patients were operated on. On presentation, there were 60 pigmented giant congenital nevi in 53 patients (Table I). Among all 61 patients at initial presentation, five patients each had two lesions and two patients had three. One patient had a giant nevus involving two different body regions. Age range of the TABLE I Distribution of Giant Congenital Nevi No. of Patients No. of Nevi Nevi thought to have malignant potential Pigmented Nevus sebaceus 4 4 Nevi without known malignant potential Woolly hair 1 1 Inflammatory linear verrucous epidermal 3 5 patients was from newborn to 16 years. No focus of malignancy or cytoatypia was identified in any patient. The deep margin of resection was positive for nevus cells in 14 resected specimens, all of which were pigmented lesions. Four of the 14 patients (29 percent) with positive deep margins later developed recurrent visible pigmentation in the reconstructed area. No patient presented with symptoms suggestive of central nervous system involvement. Magnetic resonance imaging of the brain and spinal cord was performed in five patients, each with extensive pigmented giant congenital nevi involving at least 50 percent body surface area. In one patient, an asymptomatic focus of leptomeningeal melanosis was found within the cerebellum for which no specific treatment was recommended. Reconstructive techniques consisted of expanded skin flaps, expanded skin for fullthickness skin grafts, nonexpanded fullthickness skin grafts, split-thickness skin grafts, and serial excision. Expanded flaps were used in 25 nevi, expanded full-thickness grafts were used in 10 nevi, split-thickness or nonexpanded full-thickness skin grafts were used in 13 nevi, and serial excision was used in 30 nevi. Nine nevi were operated on before 1990, equally distributed among three surgeons. Fifty-one nevi were operated on after 1989, 49 of which were operated on by one surgeon (A.K.G.). The use of split-thickness skin grafts decreased from 22 percent before 1990 to 6 percent after 1990, whereas the use of nonexpanded full-thickness grafts increased from none before 1990 to 10 percent after This change reflects the evolving preference for the use of full-thickness grafts over splitthickness grafts toward the latter portion of this series. The relationship between treatment modality and its use in single versus multiple modality treatment is shown in Table II. All five reconstructive options were commonly used in both

3 624 PLASTIC AND RECONSTRUCTIVE SURGERY, September 1, 2001 TABLE II Relationship between the Selected Treatment Modality and Combination Treatment TABLE IV Relationship between Nevus Location and Treatment Modality Single Modality (%) Multiple Modalities (%) Expanded flaps (n 25) FTSG (expanded) (n 10) FTSG (nonexpanded) (n 8) STSG (n 5) Serial excision (n 30) FTSG, full-thickness skin grafts; STSG, split-thickness skin grafts. TABLE III Number of Procedures Needed to Complete Coverage in Single Modality Treatment One (%) Two (%) Three (%) Four or More (%) Expanded flaps (n 18) FTSG (expanded) (n 6) FTSG (nonexpanded) (n 4) STSG (n 2) Serial excision (n 21) FTSG, full-thickness skin grafts; STSG, split-thickness skin grafts. Head and Neck Torso Extremities No. of nevi No. of procedures No. of modalities per nevus Single (%) Multiple (%) Expanded flaps* (%) FTSG (expanded)* (%) FTSG (nonexpanded)* (%) STSG* (%) Serial excision* (%) FTSG, full-thickness skin grafts; STSG, split-thickness skin grafts. * Percent distribution is reported relative to the number of procedures performed in the specified location. single and multiple modality treatment. Each of the five reconstructive options constituted one component of a multimodality treatment plan at least 40 percent of the time. When single modality treatment was used, multiple procedures were often required. The number of procedures needed to complete reconstruction when single modality treatment was used is shown in Table III. Serial expansion was required in six (33 percent) of the 18 nevi in which expanded flaps alone were used to reconstruct the defect, two of which required four successive stages of serial expansion for giant congenital nevi of the scalp. More than 80 percent of nevi treated with serial excision alone could be completed in two procedures or less. Three successive procedures were required in 19 percent of nevi treated with serial excision alone. The latter cases involved the knee or elbow, where increased morbidity might have resulted from the use of alternative reconstructive options. The relationship between the anatomic zone in which the nevus was located and the selected treatment modality is shown in Table IV. Expanded flaps were the most common mode of reconstruction in the extremities. Expanded flaps and serial excision were more equally distributed in the torso. Serial excision was the most common form of treatment in the extremities, and expanded flaps were used infrequently. The primary use of tissue expansion for extremity reconstruction was to provide expanded full-thickness skin grafts. Representative cases demonstrating principles of reconstruction in each of the anatomic zones are pictured in Figures 1 through 7. Head and Neck Single modality treatment of a giant congenital nevus of the scalp is shown in Figure 1. A 4-year-old girl presented with a woolly hair nevus occupying two-thirds of the occipitoparietal scalp (Fig. 1, above, left). Serial tissue expansion was performed, with new tissue expanders placed immediately after advancement of the previously expanded scalp flaps. After serial expansion in two stages, the remaining nevus occupied approximately one-third of the occipitoparietal scalp (Fig. 1, above, right). After four stages, only a negligible amount of woolly hair nevus remained (Fig. 1, below). Combined modality treatment was often required for lesions of the head and neck involving different anatomic structures. This is illustrated by a 13-year-old girl who presented with a giant congenital nevus sebaceus of the left temporoparietal scalp, postauricular sulcus, and auricle (Fig. 2, above, left). Tissue expansion was used to resurface the temporoparietal scalp in one stage (Fig. 2, above, right). Nonexpanded full-thickness skin grafts harvested from bilateral groins were used to resurface the postauricular sulcus and involved portion of the auricle (Fig. 2, below). Treatment of complex lesions of the head and neck, particularly those involving the eyelids, often required multiple modalities. This is illustrated by an 8.5-month-old girl who presented with a giant congenital nevus involving

4 Vol. 108, No. 3 / MANAGEMENT OF GIANT CONGENITAL NEVI 625 FIG. 1. Single modality treatment of a giant woolly hair nevus of the scalp with expanded flaps. (Above, left) Preoperative appearance. (Above, right) Appearance after two-stage immediate serial expansion. (Below) Appearance after four-stage immediate serial expansion. the scalp, forehead, upper and lower eyelids, and cheek (Fig. 3). Tissue expanders were placed in the scalp and the forehead, and each of these areas was reconstructed with expanded flaps (Fig. 3, above, right). Serial excision was used to reduce the nevus involving the right cheek. The residual nevus involving the right upper eyelid and its nasal extension was resected and reconstructed with a full-thickness skin graft obtained from the groin (Fig. 3, below, left). A tissue expander was then placed in the cheek, and the resulting flap was used to reconstruct the right lower eyelid and temporal extension of the nevus (Fig. 3, below, right). Torso The torso was the most common location for successful single modality treatment of giant nevi. A 1-year-old girl presented with a pigmented giant congenital nevus of the back and a second giant nevus involving the left buttock (Fig. 4). Separate single modality treatment was used for each giant congenital nevus, using two-stage serial tissue expansion for the back and two-stage serial excision for the buttock. The completed reconstruction is shown in Figure4(right). Extremities Serial excision was the preferred treatment modality for lesions at or just proximal to the knee or elbow. A 10-year-old girl presented with a pigmented giant congenital nevus of the distal right thigh just proximal to the knee (Fig. 5, left). The lesion was serially excised in three stages, spacing each stage at least 6 months apart (Fig. 5, right).

5 626 PLASTIC AND RECONSTRUCTIVE SURGERY, September 1, 2001 FIG. 2. Treatment of a giant congenital nevus sebaceus using combined modality treatment with tissue expansion and a nonexpanded full-thickness skin graft. (Above, left) Preoperative appearance. (Above, right) Appearance after onestage reconstruction of the temporoparietal scalp with expanded flaps. (Below) Final appearance after nonexpanded full-thickness skin graft to the postauricular sulcus and auricle. Similar lesions distal to the knee or elbow are difficult to treat using serial excision alone because of reduced skin compliance and reduced diameter of the distal extremity. These areas are best treated with expanded full-thickness skin grafts. A 9-month-old boy presented with a circumferential pigmented giant congenital nevus of the right forearm and hand (Fig. 6). The lower abdominal skin was expanded, and a single expanded fullthickness skin graft was harvested to reconstruct the volar surface of the forearm and hand as one unit. This reconstruction is pictured 16 months postoperatively (Fig. 6, center, left). During a second procedure, the dorsal digits and web spaces were resurfaced using expanded full-thickness grafts. Because of limitations in expanded full-thickness skin, a split-thickness graft was used to resurface the dorsal surface of the wrist and forearm. Twelve months later, a marked difference in aesthetic outcome could be seen between the full-thickness grafts covering the digits and the split-thickness grafts covering the distal forearm (Fig. 6, center, right). Over the next 3 years, there was progressive contracture of the expanded full-thickness graft reconstruction of the web spaces of the hand. This was corrected using dorsal rectangular flaps, raised from the initial full-thickness grafts, to deepen the second and third web spaces. Additional full-thickness grafts were placed on the borders of the respective digits. The first web space was deepened using a Z-plasty (Fig. 6, below). A 4-year-old girl who presented with inflammatory linear verrucous epidermal nevi involving the scalp, vulva, and both the upper and lower extremities is shown in Figure 7. The right forearm and ring and index fingers and the left index finger were the most symptomatic regions of the upper extremities, and the dorsal ankle was the most symptomatic lower extremity region. These intensely pruritic regions were surgically excised, with no effort made to obtain clear margins. The digits were resurfaced with a full-thickness skin graft harvested from the groin, and the symptomatic regions of the dorsal ankle, scalp, and vulva were each treated with serial excision in two stages. These procedures resulted in symptomatic relief of the involved areas. DISCUSSION What Are the Reasons to Operate on Pigmented and Nonpigmented Lesions, and How Extensive a Resection Should Be Performed for Each Presentation of a Giant Congenital Nevus? On the basis of our experience, an algorithm illustrating principles for the extent of resection of pigmented and nonpigmented giant congenital nevi is shown in Figure 8. Both pigmented and nonpigmented nevi can present with aesthetic disfigurement, pruritus, and altered skin integrity, and may have malignant potential. Significant aesthetic and psychosocial concerns were present with all four types of giant congenital nevi encountered, irrespective of pigmentation. The potential for malignant transformation exists only with pigmented lesions and sebaceous nevi, and only in the latter two nevi is there a need to clear the margins of resection. Excoriation with resultant alteration in skin integrity severely diminishes the quality

6 Vol. 108, No. 3 / MANAGEMENT OF GIANT CONGENITAL NEVI 627 FIG. 3. Combined modality treatment of a pigmented giant congenital nevus using expanded flaps, a full-thickness skin graft, and serial excision. (Above, left) Preoperative appearance. (Above, right) Appearance after reconstruction of the scalp and forehead with expanded flaps, and serial excision of the cheek. (Below, left) Intraoperative appearance after placement of a nonexpanded full-thickness graft to the right upper eyelid and nasal extension of the nevus. (Below, right) Final postoperative appearance after reconstruction of the right cheek and temporal extension of the nevus with an expanded flap. FIG. 4. Single modality treatment for two separate pigmented giant congenital nevi of the torso. (Left) Preoperative appearance of nevus on the back. (Center) Appearance after first of two-stage immediate serial expansion for nevus of the back, and preoperative appearance of the nevus involving the left buttock. (Right) Final appearance after two-stage immediate serial expansion for nevus of the back, and two-stage serial excision for nevus of the left buttock. of life in patients with inflammatory linear verrucous epidermal nevi. Pruritus and skin breakdown are the primary reasons to excise the latter lesions, and in patients with widespread epidermal nevi, surgical treatment should be limited to symptomatic areas.

7 628 PLASTIC AND RECONSTRUCTIVE SURGERY, September 1, 2001 the patient s surgical care, the algorithms guiding each of these aspects of the procedure must be interdependent. Because pigmented giant congenital nevi have malignant potential but are most commonly benign on presenta- FIG. 5. Single modality treatment for a pigmented giant congenital nevus proximal to the right knee using serial excision. (Left) Preoperative appearance. (Right) Postoperative appearance after three-stage serial excision. The risk of malignant transformation in pigmented giant congenital nevi remains controversial. Quaba and Wallace 1 calculated the risk of melanoma to be 8.52 percent during the first 15 years of life. A longitudinal study of a large population of patients with pigmented giant congenital nevi reported a lifetime incidence of malignant transformation of 4 to 6 percent. 7 Other authors have reported the incidence of malignant transformation to be between 2 percent and 31 percent. 8 Although the rate of malignant transformation as a function of lesion size is not known, it is assumed that this risk within a given nevus is decreased proportionate to the fraction of the lesion removed or destroyed. The efficacy of dermabrasion and laser treatment in removing or destroying nevus cells has never been established. 4 6 There are no longitudinal studies documenting decreased rates of malignant transformation after laser or dermabrasion treatment. In fact, lightening of pigmented giant congenital nevi using these techniques may make it more difficult to monitor the resultant lesion for signs of malignant transformation, because alteration in pigmentation of the lesion can no longer be followed reliably. Surgical excision remains the treatment of choice for the removal of pigmented lesions, because this technique has documented efficacy in removal of nevus cells. 5 The extent of resection of giant congenital nevi is closely linked to available reconstructive options. Because the same surgeon is usually responsible for both of these components of FIG. 6. Combined modality treatment of a pigmented giant congenital nevus involving the right upper extremity using expanded full-thickness and split-thickness skin grafts. (Above) Preoperative appearance. (Center, left) Appearance after resurfacing the volar surface of the involved extremity with a single expanded full-thickness graft. (Center, right) Appearance after resurfacing the dorsal surface of the involved extremity with a single expanded full-thickness graft from the metacarpal heads to the distal phalanges and split-thickness grafts to the proximal surface of the involved extremity. (Below) Appearance 3 years later after deepening of the first, second, and third web spaces of the left hand.

8 Vol. 108, No. 3 / MANAGEMENT OF GIANT CONGENITAL NEVI 629 FIG. 7. Preoperative appearance of a patient with diffuse inflammatory linear verrucous epidermal nevi involving the right knee (left) and the palmar surface of both upper extremities (right). tion, an incomplete resection may be indicated in certain situations. An extensive resection and reconstruction resulting in mutilation ofthe involved body part, to remove a minimal amount of residual nevus, cannot be justified on the basis of current oncologic data. The above principle is illustrated in Figure 6, center, right. In this case, small distal foci of pigmentation were not resected to preserve the eponychial folds of the fingers and digital sensory function. In some instances, nevus cells infiltrate deeply into muscle, bone, or cartilage. In such situations, the patient and family should be educated regarding the morbidity of further resection versus continued surveillance for signs of malignant transformation. Nevus sebaceus is associated with a 10 to 20 percent rate of malignant transformation after puberty. 9 Although the resultant cutaneous malignancy is most often basal cell carcinoma or occasionally squamous cell carcinoma, other carcinomas such as apocrine and adnexal tumors can occur. 10 Because of the increased risk of malignant transformation and the difficulty involved with following these lesions clinically, incomplete excision by pathologic evaluation warrants repeated excision until deep and lateral margins of resection are free of nevus cells. Guidelines for resection of giant congenital nevi without malignant potential are indicated on the basis of presentation of the nevus. Inflammatory linear verrucous epidermal nevi (Fig. 7) are intensely symptomatic lesions. 11 The treatment strategy should focus on the most severely affected areas of skin, with more complete excision directed toward the aesthetic needs of the individual patient. Woolly hair nevi of the scalp (Fig. 1) do not possess FIG. 8. Giant congenital nevi algorithm: extent of resection. SQ, subcutaneous tissue.

9 630 PLASTIC AND RECONSTRUCTIVE SURGERY, September 1, 2001 FIG. 9. Giant congenital nevi algorithm: reconstructive options. *Consider immediate serial expansion if lesion cannot be resurfaced in one stage. **Consider supplementing with splitthickness skin graft in less-visible areas if expanded full-thickness skin graft alone cannot cover defect. malignant potential, and the extent of excision is dictated by aesthetic considerations. 12 What Reconstructive Options Should Be Used after Resection of Giant Congenital Nevi, and When Is It Appropriate to Combine Reconstructive Techniques? Do Optimal Reconstructive Methods Vary in Different Anatomic Regions? On the basis of our experience, a proposed algorithm for the reconstruction of giant congenital nevi is shown in Figure 9. Reconstructive options include tissue-expanded flaps or grafts, serial excision, and either full-thickness or split-thickness skin grafts. Serial excision is the preferred treatment modality for lesions that can be excised in two or fewer procedures without distorting adjacent structures. Because increased morbidity is often associated with the use of tissue expanders or skin grafts at or just proximal to the knee or elbow joints, serial excision is also preferred for use in these areas. If more than three procedures are required to

10 Vol. 108, No. 3 / MANAGEMENT OF GIANT CONGENITAL NEVI 631 complete the resection, the former options should be considered. Tissue expansion is recommended for lesions involving the head, neck, or torso, as the reconstructive outcome, particularly in the head and neck, is far superior to that obtained with skin grafting. For large lesions requiring more than one set of tissue expanders, a subsequent set of expanders can be inserted at the time of the initial flap advancement. Although a waiting period of 2 weeks is usual, we have delayed filling the serially placed expanders for as long as 8 to 12 weeks in an effort to avoid subluxation. Even if a filling delay is necessary, serial expansion is preferable, as it avoids the need for a repeated operation for insertion of tissue expanders. Skin grafts are recommended for lesions involving the extremities distal to the knee or elbow joint. Tissue expansion in this context has greater morbidity with less potential gain because of the restricting circumference of skin envelope. Skin grafts are also preferred for reconstruction of the eyelids or ears. In these areas, the use of expanded flaps or serial excision results in distortion of involved structures. A full-thickness skin graft is always preferable to a split-thickness graft, because of both an improved aesthetic outcome and less subsequent graft contracture. An expanded full-thickness graft should be considered if donor skin limitations are problematic. The best outcome is often achieved through the use of multimodality therapy, particularly for lesions involving the face or those involving contiguous anatomic regions. No biologic skin substitutes were used in the present algorithm, because skin substitutes are currently associated with a less satisfactory aesthetic outcome than that achieved with skin grafts. Dermal allografts may be useful in creating a thicker neodermis when a splitthickness graft is required. Microsurgical techniques may be useful if reconstruction of the face as one aesthetic unit, as reported by Siebert and Longaker, 13 is required. Despite advances made in the treatment of patients with giant congenital nevi, inadequate donor tissue for reconstruction may render complete removal impossible. Complex lesions such as bathing trunk nevi involving the perineum, genitals, and perirectal area present a continued surgical challenge. Resection of these problematic nevi should be limited to areas in which reconstruction can reasonably be expected to provide a better aesthetic and functional outcome than the original lesion. Leaving residual nevus in the genital and perineal regions results in a more predictable reconstructive outcome. Adjunctive treatments for surgically unresectable portions of complex pigmented giant congenital nevi, such as phenol chemical peel, have been reported. 14 Giant congenital nevi are among the most challenging problems faced by plastic surgeons. A thoughtful reconstructive approach to these patients may help to improve their treatment outcome in future years. Arun K. Gosain, M.D. Department of Plastic and Reconstructive Surgery Medical College of Wisconsin 9200 West Wisconsin Avenue Milwaukee, Wis agosain@mcw.edu REFERENCES 1. Quaba, A. A., and Wallace, A. F. The incidence of malignant melanoma (0 to 15 years of age) arising in large congenital nevocellular nevi. Plast. Reconstr. Surg. 78: 174, Kopf, A. W., Bart, R. S., and Hennessey, P. Congenital nevocytic nevi and malignant melanomas. J. Am. Acad. Dermatol. 1: 123, Pilney, F. T., Broadbent, T. R., and Woolf, R. M. Giant pigmented nevi of the face: Surgical management. Plast. Reconstr. 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Malignant neoplasms associated with nevus sebaceus of Jadassohn. J. Am. Acad. Dermatol. 1: 545, Morag, C., and Metzker, A. Inflammatory linear verrucous epidermal nevus: Report of seven new cases and review of the literature. Pediatr. Dermatol. 3: 15, Reda, A. M., Rogers, R. S., III, and Peters, M. S. Woolly hair nevus. J. Am. Acad. Dermatol. 22: 377, Siebert, J. W., and Longaker, M. T. Salvage reconstruction of an extensive facial deformity due to congenital giant hairy nevus. Plast. Reconstr. Surg. 102: 2414, Hopkins, J. D., Smith, A. W., and Jackson, I. T. Adjunctive treatment of congenital pigmented nevi with phenol chemical peel. Plast. Reconstr. Surg. 105: 1, 2000.