Shave Excision of Common Acquired Melanocytic Nevi: Cosmetic Outcome, Recurrences, and Complications

Background. Surgical treatment of benign melanocytic lesions demands the application of simple and effective surgical techniques with the possibility of performing a histopathologic examination with an acceptable cosmetic outcome. However, recurrence rates and the cosmetic result should be taken into account because the main reason for these lesions to be removed is the patient's cosmetic improvement. The present study evaluates the results obtained by shave excision of benign pigmented lesions in terms of cosmetic outcome, recurrence rates, and complications from both a subjective and an objective point of view.
Discussion. An acceptable cosmetic result, along with a low rate of recurrence, should be the aim of the surgical treatment of benign melanocytic lesions. The results obtained in this series allow us to provide more detailed and accurate information regarding the outcome and complications expected.
Material and Methods. Shave excision of common acquired melanocytic nevi was performed. The patients were reviewed 3 months after surgery to evaluate the objective and subjective cosmetic results, recurrences, and postsurgical complications.
Results. Over a 12-week period, 204 common acquired melanocytic nevi were shaved. Objective evaluation revealed excellent results in one-third (32.8%) of the lesions excised, with a poor result in 8.3%. The likelihood of having an imperceptible scar was significantly greater in lesions excised from the face (p < .05). Ninety-eight percent of patients (  n = 192  ) declared that "the scar looked better than the original mole." Clinical and dermatoscopic recurrences were observed in 40 scars (19.6%).     

Razor Blade Surgery: Use of the Castroviejo Blade Breaker and Holder

BACKGROUND: To remove skin lesions, many dermatologists use the razor blade which may be manipulated with or without the aid of an instrument. However, the techniques previously described employ the use of an entire razor blade. OBJECTIVE: To outline a technique that is easily performed with better control of the blade and with more precise cutting than by holding the blade by hand. This report reviews the merits of razor blade use in cutaneous surgery as well as the advantages of using the Castroviejo razor blade breaker. METHODS: The method for cutting double-edged razor blades and holding the sections with a Castroviejo blade breaker is described as well as a basic guide for selecting blade size for performing shave biopsies and shave excisions. CONCLUSIONS: Using the Castroviejo razor blade breaker and holder with cut razor blades is safe and allows better control and more precise cutting than using a complete double-edged blade alone.     

Diamond laser scalpel vs. steel scalpel: a side by side comparison of cutaneous wound healing

BACKGROUND AND OBJECTIVES: To compare the cutaneous wound healing using the diamond laser scalpel with wound healing using a steel scalpel and electrocoagulation for hemostasis. STUDY DESIGN/MATERIALS AND METHODS: A prospective and randomized, comparative trial was conducted on eighteen patients. Fusiform excisions were performed using the diamond laser scalpel on one half of each excision and a steel scalpel with electrocoagulation for hemostasis on the other half. The Clinicon SureBlade diamond laser scalpel was used with the Luxar CO(2) attachment at the 6-8-W settings. Blinded assessment of adverse events and photographs were taken at 1 day, 7-10 days, 4 weeks, and 8-12 weeks. The final scar was evaluated at 8-12 weeks for cosmetic outcome and three physicians blinded to the method of excision evaluated photographs of the wounds. Histologic evaluation was performed on all excisions for collateral thermal damage. RESULTS: Investigator assessment showed no statistically significant differences between the diamond laser scalpel side and the steel scalpel side with respect to bleeding, bruising, swelling, pain, dehiscence, or final scar appearance. The mean residual thermal damage was 350.3 microm (95% CI +/- 37 microm, P < 0.001). The diamond laser scalpel scored higher on intra-operative coagulation (P = 0.20) although these differences were not statistically significant. CONCLUSIONS: The cosmetic outcomes of cutaneous excisions performed with the diamond laser scalpel are equivalent to excisions performed with steel scalpels with electrocoagulation for hemostasis.     

Shave Excision of Benign Facial Melanocytic Naevi: A Patient''s Satisfaction Survey

BACKGROUND: Shave excision is a simple and quick procedure that is widely used for removal of benign naevi. Limited published data are available on patient acceptability of this procedure or its potential cosmetic outcomes. OBJECTIVES: To assess the patient's satisfaction with the procedure, to assess the risk of recurrence, and to determine the patient's perception of the scar. METHODS: Questionnaires were sent to 93 consecutive patients who had shave excision of benign facial naevi. RESULTS: Seventy-six patients (82%) with a total of 83 naevi responded. Twenty-eight percent of naevi were reported to have recurred 12 months after shave excision. A significantly higher recurrence rate was found with hairy naevi (41%, P= 0.04). More than half of the patients reported no scar or had a white and flat scar. Nineteen percent of scars were depressed, and 15% were raised; 7% were pigmented. The majority of patients were satisfied with the results. CONCLUSIONS: Despite a high recurrence rate, most patients were satisfied with the cosmetic outcomes after shave excision of benign facial naevi. The results of this study have helped us to provide our patients with more accurate information regarding cosmetic outcomes.     

The Surgical Management of Spitz Nevi

BACKGROUND: The biologic behavior of Spitz nevi and atypical Spitz nevi ranges from completely benign to the rare malignant melanoma. Various recommendations for the surgical approach to these lesions have been proposed. OBJECTIVE: To determine any trend in the surgical management of Spitz nevi and atypical Spitz nevi among a community of dermatologists. METHODS: Retrospective review of the clinical features, surgical management and outcome of 89 patients with the diagnosis of Spitz nevus or atypical Spitz nevus. RESULTS: All biopsy techniques had a high incidence of involved margins: shave (67%), excision (28%), and punch (21%). Of the atypical Spitz nevi with positive margins on biopsy, there was a trend (7/9) toward reexcision with narrow margins (average 2.2 mm). CONCLUSION: The majority of atypical Spitz nevi incompletely removed by biopsy were excised with narrow uncontrolled margins. A stratified surgical approach depending on the clinical and histopathologic features of the Spitz lesion is proposed. More aggressive surgical management of Spitz lesions with atypical features may be warranted. Further studies to determine the biologic potential of these lesions are needed.     

Needle-Guided Shave Excision With Ultrasonographic Assistance: A New Technique

BACKGROUND: A lack of control in the deep margin of shave excision is a drawback of this technique. OBJECTIVE: To describe a more precise shaving technique by sonography with the use of a fine injector needle as a depth marker. METHODS: After having examined the invasion levels of 40 benign skin lesions, a fine injector needle was intentionally threaded into the dermis horizontally just beneath the required shaving plane. Correct placement of the needle was ensured by sonographic examination after possible reinsertion trials. Large lesions needed several needles to be inserted. The tissue above the needles was then shaved off, whereas the deep dermal layer was protected. RESULTS: Histologic examination revealed that 77% of superficial and intermediate-thickness lesions were removed totally without disturbing the derma-fat junction. CONCLUSION: The needle-guided technique was found to be effective in the control of the deep margin of shave excision.     

Atypical genital nevi. A clinicopathologic analysis of 56 cases

Atypical genital nevi are rare melanocytic lesions that most commonly arise on the vulva of young women. They are currently regarded as nevi of special sites, in that despite histologically worrisome features, their clinical behavior is reportedly benign. However, only few studies with limited follow-up data are available. To better characterize the clinical presentation and behavior of these lesions and to further delineate their histologic features, we retrieved 56 atypical genital nevi arising in the lower female genital tract from our departmental and consultation files. The 56 lesions arose in 55 female patients with a median age of 26 years (range, 6 to 54 y). The dominant histologic feature was a lentiginous and nested junctional component composed of prominent round or fusiform nests, which often showed retraction artifact and/or cellular dyscohesion. Cytologic atypia was mild in 11 cases (20%), moderate in 34 (60%), and severe in 11 (20%). Ten cases (18%) showed focal pagetoid spread, with extension to the granular layer and stratum corneum in 1 case. The atypical junctional melanocytic proliferation was associated with a large common dermal nevus component that dominated the lesion in 26 cases (46%). Adnexal spread (46%) and nuclear atypia of melanocytes situated in the superficial dermis (39%) were relatively common, but dermal mitoses (7%) were uncommon and maturation was present in all cases. A broad zone of dense eosinophilic fibrosis within the superficial dermis was a frequent finding (41%). Clinical follow-up was available in 45 cases (80%) with a median follow-up period of 3.5 years (range, 1 to 16 y). Only 1 lesion recurred, 1.5 years after the initial excision. The original nevus in this patient had only mild cytologic atypia and was present at the margins of excision. The recurrent/persistent nevus was reexcised, and there was no further clinical recurrence in 11.5 additional years of follow-up. Our data support the hypothesis that atypical genital nevi have a benign clinical course despite their occasionally striking cytologic and architectural atypia. Awareness and recognition of this group of melanocytic lesions is important to avoid over diagnosis as melanoma with subsequent wide excision and possibly sentinel lymph node biopsy.     

Acquired Melanocytic Lesions and the Decision to Excise: Role of Color Variegation and Distribution as Assessed by Dermoscopy

BACKGROUND: Because melanoma may sometimes be difficult to differentiate from nevi with clinical atypia, many benign lesions also undergo surgical removal. OBJECTIVE: To assess color type and distribution in dermoscopic melanocytic lesion images and to analyze the influence of color parameters on the diagnostic process and the decision to excise. METHODS: Overall, 603 images, referring to 112 melanomas and 491 nevi, were retrospectively subdivided into four groups: "clearly benign," "follow-up," "dermoscopic atypical nevi," and "dermoscopic melanomas," according to their dermoscopic aspects. The frequency of color type, number, and asymmetry were evaluated on digital images. RESULTS: With respect to lesions not eligible for excision according to dermoscopy (but excised for cosmetic reasons), those excised with a suspicion of malignancy showed a higher number of colors, whose distribution was also more asymmetric. Moreover, the frequency of the presence of black and blue-gray progressively increased from clearly benign lesions to atypical nevi and dermoscopic melanomas. CONCLUSION: In dermoscopic images, color parameters are essential elements for the diagnosis of atypical nevus, which can be differentiated from both a clearly benign lesion and a melanoma. Furthermore, pigmentation asymmetry and the presence of blue-gray represent the main color features, which should lead to the decision to excise.     

Method of Biopsy and Incidence of Positive Margins in Primary Melanoma

Background The staging of patients with primary melanoma is dependent on adequate sampling of the tumor thickness. Initial biopsies with a positive deep margin suggest inadequate sampling, potentially limiting accurate staging and affecting treatment decisions. Methods To determine the efficacy of shave biopsy to adequately sample the tumor, we retrospectively reviewed our pathology database for original pathology reports of primary melanomas accessioned between 01/01/04 and 6/30/05. The biopsies were evaluated by technique, the presence of tumor at the margins of the specimen, and specimen thickness. Results We identified 240 cases of primary melanoma; 223/240 were analyzable. The specimens were divided by biopsy technique (excisional, n = 51; punch, n = 44; and shave, n = 128). Shave and punch specimens had a significantly higher percentage of positive margins than excisional specimens (50, 68, and 16%, respectively; P < 0.0001). Shave specimens had a significantly higher percentage of positive deep margins than punch or excisional specimens (22, 7, and 2%, respectively; P = 0.0009). For melanomas ≤1 mm, shave specimens had a significantly higher percentage of positive deep margins than punch or excisional specimens (17, 0, and 0%, respectively; P = 0.0014). There was a significant difference in specimen thickness (P = 0.0005), with shave specimens being the thinnest. Conclusions The presence of tumor at the lateral margin of punch biopsies is an expected result, since this method is often used to diagnose lesions with a large diameter. The presence of positive deep margins in 22% of shave biopsy specimens compromises the ability of this technique to properly stage patients.     

皮肤黑色素细胞痣的手术治疗探讨

目的:探讨黑色素细胞痣患者的群体分布,比较不同手术方法及效果。方法:收集我院2002～2007年住院手术治疗的877例黑痣患者病历,分析患者基本情况、黑痣部位、住院及手术情况。结果:手术患者中1～10岁为610例,占69.59%;手术部位大多为阳光慢性暴露部位,共722例,占82.33%;一般经一次手术即可治愈,占74.00%;最常采用的手术方式为单次或分次切除术,切除后直接缝合或植皮,共计729例,占83.12%。结论:患者对暴露部位的黑痣治疗态度积极,对易恶变的隐蔽部位未引起足够重视。医师及患者均对治疗时间短的黑痣切除术的接受程度高。     

Radical Resection of Giant Congenital Melanocytic Nevus and Reconstruction With Meek-Graft Covered Integra Dermal Template

BACKGROUND: Giant congenital melanocytic nevi represent a surgical challenge, particularly in cases in which the size of the nevus exceeds certain extend and malignant transformations have to be considered. OBJECTIVE: To discuss through case report considerable surgical options when extensive giant congenital melanocytic nevi with malignant transformation are encountered. METHODS: We present an unusual case of a giant congenital melanocytic nevi of the entire back of a 44-year-old patient. To achieve radical resection with direct appropriate wound closure and acceptable outcome, the integument of the entire back was excised and covered with Integra, followed by split-thickness skin grafting after stable integration of the matrix. RESULTS: The approach resulted in a complete excision of the tumor and acceptable cosmetic and excellent biomechanical outcome. CONCLUSION: The introduced practice demonstrates a useful alternative to established methods, particularly if tumor excision in large areas and subsequent wound closure might be achieved in one procedure.     

Management of congenital nevocellular nevi

The risk of malignant change in a congenital nevocellular nevus is approximately 10 percent and is the chief indication for early excision. In 90 percent of patients, removal is simple; the remainder present with major cosmetic deformities and are difficult to manage successfully. Seventeen children (newborn to 17 years of age) were treated, including 11 children with localized lesions and 6 children who presented with abnormalities that covered 5 to 50 percent of the total body surface area. In those cases not amenable to primary removal, serial excision was performed at an average of 6 month intervals. Staging was determined by the softening and mobility of the surrounding tissue at follow-up evaluation. No effort was made to provide a cosmetic closure until the final stage. Utilizing this technique, complete removal of congenital nevocellular nevi is possible without the need for disfiguring skin grafts, even for the giant variety. Early excision obviates the risk of malignancy and provides satisfactory cosmetic results.     

Noncoherent-intense-pulsed light for the treatment of relapsing hairy intradermal melanocytic nevus after shave excision

BACKGROUND AND OBJECTIVE: Few reports about melanocytic lesions treatment by means of noncoherent-intense-pulsed light (NCIPL) have been published. Here we evaluate the clinical results of a relapsing hairy intradermal melanocytic nevus treated with a noncoherent-intense-pulsed light source. STUDY DESIGN/MATERIALS AND METHODS: A facial repigmented hairy intradermal melanocytic nevus that relapsed after shave excision, received four treatment sessions of a noncoherent-intense-pulsed light source (EpiLight, ESC Medical Systems Ltd, Israel) with the following parameters: 755 nm, a fluence energy of 40-42.5 J/cm(2), triple mode, a pulse width of 3.8 ms, and a delay of 20 ms, at 4-week intervals. RESULTS: Complete pigment clearance and hair removal was obtained. We have neither observed repigmentation nor hair regrowth after a 6 month-follow-up. No side effects were documented. CONCLUSIONS: Noncoherent-intense-pulse light is an effective treatment for hairy-pigmented melanocytic nevus.     

Comparative genomic hybridization for the diagnosis of melanoma

Despite advancements in protocols, a subset of melanocytic lesions continues to pose diagnostic challenges. This is particularly true in the pediatric population where certain congenital nevi mimic melanoma. Recently, comparative genomic hybridization (CGH) has been utilized to support diagnoses of melanocytic lesions based on DNA copy number changes. Because distinct differences in copy number changes have been shown to occur in malignant melanoma and benign nevi, CGH can be a useful adjunct when diagnosis based on histology alone is indeterminate. The authors discuss the benefits of using CGH to aid in the diagnosis of melanocytic lesions that are difficult to characterize as malignant or benign based on clinical and histologic features alone. This paper presents a brief clinical report and review of the literature. A 13-year-old Caucasian male presented to an academic tertiary care medical center after a shave biopsy unexpectedly revealed malignant melanoma with positive deep margins. Following complete excisional biopsy, the diagnosis of malignant melanoma with depth of 0.92 mm was confirmed, both by the home institution's pathologist and by consultant dermatopathologists at two separate academic tertiary medical centers. Sentinel lymph node biopsy revealed a small focus of metastatic melanoma, this lead to a left-sided modified radical neck dissection. All nodes removed were negative for disease, and surgical and postsurgical care was uncomplicated. Before proceeding with interferon therapy, CGH was performed on the tissue from the primary lesion. Other than a slight amplification of chromosome 16p, no other aberrations were detected favoring a benign lesion. Ultimately, the diagnosis was amended to compound melanocytic nevus of the nose with benign nevus cell rest in the sentinel node. While histopathologic evaluation is the current gold standard for the diagnosis of melanoma, there are many cases where it is inaccurate. The use of CGH in the evaluation of histologically equivocal lesions may allow certain patients to avoid invasive procedures and associated morbidities. The authors propose that, in these select diagnostically challenging cases, tissue analyses by CGH may be beneficial before proceeding to more invasive procedures such as sentinel node biopsy and complete lymphadenectomy.     

Malignant melanoma of the external ear

Twelve patients with primary melanoma of the external ear were treated during a 10-year period. Ten patients were males. Median melanoma depth was 2.1 mm and seven patients had lesions deeper than 2 mm. Eight of 12 lesions were either Clark level IV or V. Six patients had wedge excisions of the primary lesion and all developed recurrent disease (local: three). Six patients underwent wide excision and none developed local recurrence. All patients with primary disease less than 2 mm are alive. Only two of seven patients with lesions deeper than 2 mm have survived. The definitive excision for melanoma of the ear should encompass wide margins despite the cosmetic consequences. Lesser procedures inevitably lead to local recurrence. Melanoma deeper than 2 mm penetration on the ear in our series had a poor prognosis.     

Basal cell carcinoma histological clearance margins: an analysis of 1539 conventionally excised tumours. Wider still and deeper?

An analysis of peripheral and deep margins of histological clearance around 1539 consecutive basal cell carcinomas excised by conventional surgery showed that 81 lesions (5.3%) were incompletely excised peripherally; 36 lesions (2.3%) were incompletely excised deeply; 13 lesions (0.8%) were incompletely excised peripherally and deeply. Nine hundred and ninety-six lesions (65%) were excised with a peripheral histological clearance margin<5mm (0.1-4.9mm), whereas 1303 lesions (85%) were excised with a deep histological clearance margin<5mm (0.1-4.9mm). Four hundred and eight lesions (27%) had a peripheral histological clearance margin of 5.0-9.9mm, whereas 170 lesions (11%) had a deep histological margin of 5.0-9.9mm. Peripheral histological clearance margins exceeded 10mm in 41 lesions (3%) and deep histological margins exceeded 10mm in 17 lesions (1%). Thus 30% of peripheral histological margins were 5mm or more but only 12% of deep histological margins were 5mm or more. Despite a relative sparing of deep tissue, incomplete excision in depth affected only 36 lesions compared with 81 incomplete peripheral excisions. Peripheral histological clearance was <5mm (0.1-4.9mm) for 55% of temple lesions, 50% of scalp lesions and 43% for limb lesions. In the cosmetically sensitive areas of peri-orbital region, nose, cheek, lip, neck and chin more than 70% of lesions were excised with a peripheral histological margin<5mm. This study of conventional surgical excision of basal cell carcinomas with an incomplete excision rate of 8% has shown that 65% of lesions were excised with <5mm histological clearance peripherally and 85% with <5mm deep clearance. These figures for 'normal tissue sacrifice' are not excessive when compared with those of 'tissue sparing' Mohs' micrographic surgery in which the operator may take a margin of several millimetres of normal tissue in the initial 'slice', or in the subsequent 'safety margin' beyond the eventual tumour free plane. However, peripheral margins did exceed 5mm in more than 30% of lesions of scalp, temple and forehead, and for these sites where even with loupe magnification the tumour edge could be difficult to define, either frozen section control or Mohs' technique, might with benefit be more often used in order to minimise normal tissue sacrifice.     

Myofibroblasts in healing laser excision wounds.

BACKGROUND AND OBJECTIVE: The lack of myofibroblasts, cells responsible for wound contraction, has been suggested to be the underlying factor to the clinically observed minimal contraction in CO2 laser wounds. However, the histologic background to this phenomenon in laser excisions has not been thoroughly clarified. Therefore, we analyzed the expression of myofibroblasts in healing laser excisions and control excisions made by scalpel. STUDY DESIGN/MATERIALS AND METHODS: CO2 laser (continuous wave, 5 W) or scalpel excision wounds were created in the dorsal tongue mucosa of 144 rats. Sixteen additional rats were kept as untreated controls. Specimens from the tongues were cut at 16 different healing time points and fixed in 10% formalin. Immunohistochemical stainings with monoclonal antibodies to vimentin and to alpha-smooth muscle actin were done to determine microscopically the contractile type of myofibroblasts. RESULTS: The maximum amount of myofibroblasts was almost three times higher in scalpel than in laser excisions. The peak value was reached at 4 days in laser and at 3 days in scalpel wounds. The increase reverted to normal levels at 14 days in laser and at 6 days in scalpel wounds, respectively. CONCLUSION: Myofibroblasts appeared and disappeared slower in laser wounds. There were clearly fewer myofibroblasts in CO2 laser than in corresponding scalpel excisions known to heal by contraction. The lack of contractile myofibroblasts, therefore, is suggested as the reason for the minimal degree of contraction in CO2 laser excision wounds.     

Genomic analysis of blue nevi and related dermal melanocytic proliferations

Blue nevi are benign dermal melanocytic proliferations that can sometimes share overlapping microscopic features with melanoma. We used comparative genomic hybridization to analyze three groups of dermal melanocytic proliferations. Group 1 consisted of 10 cellular blue nevi and 1 deep penetrating nevus, none of which showed chromosomal aberrations. Group 2 consisted of 11 lesions that were histopathologically ambiguous. Three of these lesions demonstrated chromosomal aberrations (three or fewer per lesion). Group 3 consisted of seven histopathologically malignant lesions, each showing three or more chromosomal aberrations. Moderate to severe cytologic atypia and a mitotic rate of three or more mitoses per 10 high power fields were present in six of eight (75%) lesions that had at least three chromosomal aberrations but were absent in 15 of 20 (75%) lesions without chromosomal aberrations. Necrosis was present in four of the 29 (13%) lesions, with every lesion with necrosis demonstrating three or more genomic abnormalities. In conclusion, histopathologically unequivocally benign or malignant dermal melanocytic proliferations show nonoverlapping patterns of chromosomal aberrations. Ambiguous lesions can be separated into lesions with and without chromosomal aberrations. Future studies with clinical follow-up are necessary to determine which aberrations are most informative for classification of these lesions.     

Frequency of Seborrheic Keratosis Biopsies in the United States: A Benchmark of Skin Lesion Care Quality and Cost Effectiveness

BACKGROUND: Most seborrheic keratoses may be readily clinically differentiated from skin cancer, but occasional lesions resemble atypical melanocytic neoplasms. OBJECTIVE: To evaluate the frequency, cost, and intensity of procedures performed that result in the removal and histopathologic evaluation of seborrheic keratoses. METHODS: Episodes of surgical removal of lesions that were identified as seborrheic keratoses by histologic identification were determined using Medicare Current Beneficiary Survey data from 1998 to 1999. These episodes were defined by a histopathology procedure code that is associated with a diagnosis code for seborrheic keratosis. We then identified what procedure(s) generated the histopathology specimen. Biopsy and shave procedures were considered "low intensity," whereas excision and repair procedures were considered "high intensity." RESULTS: Dermatologists managed 85% of all episodes of seborrheic keratoses. Dermatologists managed 89% of seborrheic keratosis episodes using low-intensity procedures compared with 51% by other specialties. For nondermatologists, 46% of the treatment cost (9 million US dollars) to Medicare was generated from high-intensity management compared with 15% by dermatologists (6 million US dollars). CONCLUSION: There is a significant difference in the management of suspicious pigmented lesions between dermatologists and other specialists. This affects both the cost and quality of care.