Surgical Science, 2011, 2, 453-455
doi:10.4236/ss.2011.29099 Published Online November 2011 (http://www.SciRP.org/journal/ss)
A Facelift for a Two-Year-Old: Alternative Use of Facelift
Approach, to Achieve Serial Excision of a Medium Sized
Congenital Naevus, in a Two-Year-Old Patient
Marco Malahias, Diaa Othman, George Spyrou
Plastic Surgery Department, Pinderfields Hospital, Wakefield, UK
Received June 30, 201 1; revised September 22, 2011; acce pted October 29, 2011
Abstract
Historically, face-lifting consisted of elevating the skin, placing it under tension to reduce the wrinkles, re-
secting the skin needed to accomplish this, and then securing the resected edges. However, over time, facelift
surgery evolved beyond the Dorland’s definition of “rhytidectomy” (excision of skin for the elimination of
wrinkles [1]) and various different techniques and indications have been described. We report of the pre-
auricular facelift approach, as described by Skoog [2] for alternative use: The excision of a giant cell tumour,
utilizing this facelift technique to achieve serial excision from a two year old, male patient’s face. This has
resulted in a satisfactory aesthetic outcome and scar alignment in favourable area as well as excision of a
significant part of the lesion, and awaiting further serial excision for completion.
Keywords: Facelift, Congenital Naevus, Facial Reconstruction
1. Purpose
A two-year-old male patient was born with a giant naevus
involving most of the left side of his face (Figure 1). The
lesion had increased both in size and pigmentation as he
grew older, which prompted the parents to seek medical
advice, resulting in their referral to our unit. The lesion’s
diameter measured (6 cm × 7.5 cm). The main concern
with this patient was the potential risk of malignant
transformation and the overall cosmetic appearance of
this young child, which may have led to him being bul-
lied by his peers, once he reached school age.
2. Method
Several management options where considered including
Laser therapy, dermabrasion and excision followed by
sheet grafting, tissue expansion and serial excision. Both
dermabrasion and laser therapy where not feasible, due to
the lack penetration to deeper tissues. Excision and sheet
grafting was an unacceptable solution for the parents, who
rejected the idea of visible scars in their son’s face.
The idea of tissue expansion was abandoned, due to
the lack of sufficient, unaffected tissue between the angle
of the mouth and the most anterior border of the pig-
mented area. Therefore, after meticulous planning and in
depth discussions with the parents, we decided on the
option of serial excision of the lesion and chose the pre-
auricular facelift approach, traditionally associated with
rhytidectomy in older patients usually beyond their fifth
decade of life.
The skin of the left side of the face was incised via a
standard pre-auricular approach; a single dose of intra-
venous antibiotic (cefuroxime) was administered at in-
duction. The skin with the overlying giant naevus was
dissected mobilised and elevated (Figure 2). The intra
operative findings included: 1) abnormally pigmented-
skin, which was of variable thickness, resulting in areas
that were easily perforated by the instruments routinely
utilized for skin retraction; 2) subcutaneous fat atrophy;
3) an increase in tissue elasticity al lowing easy stretch of
the pigmented skin to achieve maximal ex cision, without
distorting the angle of the mouth or altering the position
of the ala of the nose.
3. Result
During the first of a total of three planned procedures
40% of the initial lesion was excised (Figures 3 and 4).
Skin closure, without excessive tension was achieved

454 M. MALAHIAS ET AL.
Figure 1. Preoperative lesion.
Figure 2. Intraoperative dissection.
Figure 3. Immediate postoperat i ve closure.
Figure 4. Immediate postoperative closure with area excised.
and a small suction drain was placed in situ for 24 hours,
to collect any excessive ooze from the wound. The sub-
sequent stages where planned six to nine months apart.
4. Discussion
Congenital nevi are present at birth and result from a
proliferation of benign melanocytes in the dermis, epi-
dermis, or both. Occasionally, nevi that are not present at
birth but are histologically identical to congenital nevi
may develop during the first two years of life. This is
referred to as congenital nevus tardive [1].
The aetiology from the congenital melanocytic naevi
remains unclear. The melanocytes of the skin originate in
the neuroectoderm, although the specific cell type from
which they deriv e remains unknown [2-4 ].
Congenital nevi have been stratified into 3 groups ac-
cording to size. Small nevi are less than 1.5 cm in great-
est diameter, medium nevi are 1.5 - 19.9 cm in greatest
diameter, and large or giant nevi are greater than 20 cm
in greatest diameter. Giant nevi are often surrounded by
several smaller satellite nevi. For giant congenital mela-
nocytic nevi, the risk of developing melanoma has been
reported to be as high as 5% - 7% by age 60 years [5,6].
Because of the increased risk of melanoma associated
with congenital nevi, attempts have been made to distin-
guish congenital nevi from acquired nevi on the basis of
histology. Distinguishing histologic features include: 1)
involvement by nevus cells of deep dermal appendages
and neurovascular structures (including hair follicles,
sebaceous glands, arrector pili muscles, and within blood
vessels walls); 2) extension of nevus cells to deep dermis
and subcutaneous fat; 3) infiltration of nevus cells be-
tween collagen bundles; and 4) a nevus cell-poor sub
epidermal zone [7-9].
5. Conclusions
Surgical removal of congenital melanocytic nevi is per-
formed for two main reasons, first, to improve the cos-
metic appearance of the patient and second , to reduce the
likelihood of malignant transformation. The use of a
facelift approach to solve this predicament shows how
versatile surgical skills need to be, in order to find an
answer to any operative challenge.
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