Nevus Removal 101
Dr. Bruce Bauer
By , Staff Writer, Nevus Outreach
Whether or not to remove a congenital melanocytic nevus (CMN) is a decision no parent wants ever to face. But when a baby is born with a large nevus, parents must decide what they believe is best for their child, who is unique and precious.
There are excellent reasons for either choice. Families who choose to remove a nevus, do so for two overriding reasons: First, they wish to reduce the risk of melanoma, a serious form of cancer associated with a very small number of persons with CMN. Second, they wish to improve appearance, which can be fundamental to improving one’s overall psychosocial state.
“Surgery is not the answer for every patient, but many can benefit,” says Bruce Bauer, MD, FACS, FAAP, who heads the Division of Plastic Surgery at NorthShore University Health Systems, in the suburbs north of Chicago (Highland Park) and directs Pediatric Plastic Surgery.
An ideal treatment choice, Bauer believes, takes into account both medical and aesthetic concerns. As a large nevus carries a higher risk for malignant change, a preoperative plan is likely to satisfy those concerns first. Satellite nevi don’t carry the same risk as a large nevus, he says, but children can benefit significantly from the removal of larger satellites. Even a small nevus in a prominent place can be troublesome.
“Not all children experience stigma, but some do,” he points out. “Reconstructive surgery for cosmetic and psychological purposes is just as important as surgery for medical purposes.”
Bauer, who started his practice in 1979, has removed more nevi than any other surgeon in the world. While a variety of procedures are used worldwide to remove this kind of birthmark, Bauer approaches this end goal with staged surgical procedures, most commonly using tissue expansion as the primary means of gaining additional normal tissue needed for these complex reconstructions. He first places temporary tissue expanders in a patient to grow additional skin. Once a full-thickness new layer of skin has grown, he removes the nevus. This new flap of skin with its rich blood supply nourishes the site where the nevus was removed, allowing it to heal.
Surgery and recovery
Approximately 12 weeks after placing a temporary expander in a patient, the child returns to Chicago to have the expander removed, along with the nevus. Curiously, children seem not to be as distressed about this visit as much as one might expect.
At the 2012 Nevus Outreach Conference in Texas, one mom reported that her little girl tells her friends that “it’s cool to have a birthmark, because I get to go to Chicago to see this great doctor.”
Bauer suspects that a big part of his kids expressing a desire and excitement about coming to the Chicago north suburbs is because he and his team have come to be considered family. “I think it is our getting down on the floor and talking directly to kids in a language they understand — and not limiting our discussion to the parents — that may have the greatest impact. We try to demonstrate in all that we do that, even if some things hurt, we make every effort to keep that to a minimum.
“Being in the Chicago area, too, is a time when many of our patients bask in becoming the center of attention, which, for some, is the only time that this may be the case.
“We become a big part of their lives — for years in many cases. As the kids grow older, they come to further appreciate the fact that, whatever we put them through, in the end, has helped make them feel better about themselves.”
The length of the actual surgery for reconstruction depends on what needs to be done. If Bauer is doing something relatively straightforward on the trunk, he may be able to do it in as little as 1/2 to 2 hours, he says. A facial nevus might be entirely different.
“If I am doing a big nevus on the face, I never simply cut out the nevus and fill in the hole. It’s a step-wise progression. First, I fix brows in the right place and shift tissue over. Then, I bring the next piece in place. If I am doing the whole center of the face — the nose, the forehead, the scalp — surgery could be six hours, but probably not much longer.”
Bauer’s goal is to remove as much of the nevus as possible, while minimizing the scar. A scar may be better accepted than a nevus, he believes, but a bad scar is still a bad scar. The patient has the best chance for full acceptance when his appearance is close to normal.
But removing every last nevus cell, while certainly a goal, is not always possible. In some cases, the decision is made to leave nevus in place, where the risk of functional problems or complications outweighs the risk of later malignancy.
In other cases, a group of nevi lighter in color sometimes develops along the border of the incision and he can’t see these edges so well. He does a lot of kids at six months, though. Most nevi will have a distinct margin at that age and the risk of nevus appearing later is slim. He does not see those nevi coming back. Others with indistinct margins may accept some later nevus appearance rather than sacrifice normal tissue in the earlier excision.
As with the first surgery, when he places the tissue expanders, Bauer does a nerve block on children, so they awake pain free. Afterwards, pain medication such as Tylenol and Motrin (or Tylenol with codeine in children more than a year of age) helps to reduce a child’s discomfort as he or she heals. Most kids are on pain meds for about one week. It is emphasized, though, that if a child is uncomfortable, it is important to continue medication and not worry about the short-term period leading to a risk of dependency. Bauer also prescribes antibiotics for the first week following surgery.
If the surgery is extensive, children may end up with low blood counts in the early post op period, but as long as their fluid balance is good then transfusion is not needed. Throughout his years of treating nevi, only a handful of patients have ever been transfused. Bauer may have transfused these kids in the past. He doesn’t have the same concerns today, though, because as long as the child’s fluid balance is good, and he is healthy otherwise, the blood count just comes back.
“It’s pretty amazing, really. You’d think this surgery would be hard on the child, but kids are resilient. Most can just adapt to whatever. It becomes more of an issue getting parents through this.”
But, actually, parents rise to the occasion given a little time. Bauer says that some of these kids that he’s been doing these large nevus removals on are on their third and fourth expansion. He’s thinking mom and dad really need a break at this point. After their child has been brought into recovery, Bauer goes to talk with the parents in the waiting room and is amazed to find that they are already calling Kristi to schedule the next surgery in about four months. They know it will take a while to get on schedule and they don’t want to miss an opportunity.
“Don’t you want to take a break for a while?” I’ll ask them. “No, we want to keep going,” they say.
Kids taking the lead
“As kids get older sometimes they’ll say, ‘I don’t want any more for a while,’” says Bauer.
“Then later they will come back and say, ‘I want to get this done.’
“Working with kids as long as I have, I can recognize that they are far more capable of voicing these issues than a lot of people give them credit for.”
In fact, he tells the story of one teen, who was going through tissue expansion and didn’t even allow an upcoming prom to interfere with her goal. Her prom pictures show her forehead expander well in view, says Bauer.
And sometimes an individual wants a nevus removed, but it doesn’t happen, not because the parents refused, but because the surgeon doesn’t have the confidence to perform the surgery.
“One of my most demonstrative patients was a teenager with a facial nevus, who had been deprived of surgery that she wanted for this reason.”
In this case, before this young lady started college, she had two small surgeries with Bauer in Chicago. Before and after photographs show an incredible difference — not just in her appearance, but in her personality as well.
“Surgery totally changed her relationship with her family, too,” Bauer says.
Most surgeons are familiar with treating small and intermediate size nevi, Bauer says, but they find the complications of removing a large nevus too high to be comfortable with.
“What seems to happen a lot is that surgeons who are uncomfortable doing this and don’t have a lot of experience, tend to say, ‘Well, let’s do something else first.’ Or, ‘Let’s wait till the child is older,’ instead of doing it now.”
That surgeons worry about removing larger lesions is not surprising, as they learn little about tissue expansion in medical school, Bauer says. No place does as much as he does in Chicago, he knows, so he is happy to help anyone who asks. He consults regularly with surgeons over the Internet by sharing photos and suggestions. And some come to Chicago to study with him. In addition, he trains residents and fellows from the Plastic Surgery Program at the University of Chicago, Pritzker School of Medicine, where he is a clinical professor of surgery.
Some of the most fascinating before and after photos Bauer shares with families and surgeons track a single child over time. One series, for example, tracks the surgeries of one patient from when she was a baby, up through elementary school and beyond. She is now a beautiful young woman and, after all of the tender loving care she personally received in Chicago, she was moved to become a caregiver herself. She is now a pediatric nurse in the western suburbs of Chicago. Other patients have followed similar career tracks.
Even after 30-plus years, Bauer is enthusiastic meeting the many challenges of his vocation, day after day. “We see patients for a long, long time,” he says. “The compilation of this information will continue to refine what we do and will increase more and more the patients we can treat. We are always learning — looking at our greatest success and asking what we could have done better.”
One thing, however, remains very clear.
“I could never do all of this without Susan, Mim, and Kristi, he says. “They are great.
“And as our patients get older, they appreciate the fact that, outside of their immediate families, few people care about them as much as we do.”
Bruce Bauer, MD: www.plasticsurgery.northshore.org/our-team/bruce-bauer