Plastic and Reconstructive Surgery • October 2014 own data clearly show that surgical patients have no higher rate of negative endpoints related to melanoma or death than those who never underwent treatment. The histologic correlate they use to support the above theory is an entity called “pseudomelanoma.” This process, first termed by Kornberg and Ackerman in 1975, describes benign recurrent pigmentation of an incompletely excised nevus. Many authors have derided the nomenclature as being misleading. The references used in the article associating pseudomelanoma with a deleterious process do nothing of the sort. They include two case reports of benign recurrent nevus following laser treatment, a benign recurrent acquired nevus in a skin graft donor site, and a letter to the editor describing pigment changes following dermabrasion in a 64-year-old man with rhinophyma and no nevus history. The final “supporting” article describes repigmentation of large congenital melanocytic nevi treated by curettage and dermabrasion, recommending against these treatments in deeper nevi. Partial excision techniques such as laser, dermabrasion, and curettage are known to leave deeper nevus cells behind and therefore commonly result in repigmentation. As such, these methods are being abandoned by most surgeons who routinely treat congenital melanocytic nevi. It also needs to be emphasized that there has never been a report or a suggestion that any of these treatments predisposes individuals to malignancy. It is our contention that the use of the aforementioned references as justification against surgery is completely invalid. Although there are many valid reasons for or against surgery, perpetuation of the aforementioned biases should be discouraged. This is not only harmful to the scientific understanding of congenital melanocytic nevi, but serves to spread misinformation to the lay public, which in turn creates a barrier that hinders rational discussion of treatment options. DOI: 10.1097/PRS.0000000000000546
Bruce S. Bauer M.D. Sara R. Dickie, M.D. Ashfaq A. Marghoob, M.D. Division of Plastic and Reconstructive Surgery NorthShore University HealthSystem Northbrook, Ill. Correspondence to Dr. Dickie Division of Plastic and Reconstructive Surgery NorthShore University HealthSystem 501 Skokie Boulevard, Suite 250 Northbrook, Ill. 60062 [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Arad E, Zuker RM. The shifting paradigm in the management of giant congenital melanocytic nevi: Review and clinical applications. Plast Reconstr Surg. 2014;133:367–376.
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2. Krengel S, Hauschild A, Schäfer T. Melanoma risk in congenital melanocytic naevi: A systematic review. Br J Dermatol. 2006;155:1–8. 3. Kinsler VA, Birley J, Atherton DJ. Great Ormond Street Hospital for Children Registry for Congenital Melanocytic Naevi: Prospective study 1988-2007. Part 2—Evaluation of treatments. Br J Dermatol. 2009;160:387–392.
Reply: The Shifting Paradigm in the Management of Giant Congenital Melanocytic Nevi: Review and Clinical Applications Sir:
Thank you for allowing us to respond to the letter addressing our article. We are actually quite impressed that the article has generated such interest and underscores its importance. The letter is written by authorities in the field of congenital melanocytic nevi and needs to be heard. We are pleased to respond. First, the authors claim that we base our current treatment philosophy on the opinion of one institution and one clinician. Our treatment algorithm is in fact based on data from several studies and several institutions, including our own. We conclude the following: 1. The risk of melanoma in patients with giant congenital melanocytic nevi is generally higher than in the general population (0.7 to 2.9 percent versus 0.6 percent). 2. Patients with giant congenital melanocytic nevi of the trunk or multiple satellite lesions have the highest risk and may account for most of the elevated risks mentioned (patients with lesions of the head and extremities run a low risk). 3. There is no proof that surgery lowers the risk for melanoma. We quoted two systematic reviews, by Krengel et al.1 and by Watt et al.2 Both reviews demonstrate an association between large lesion size and high risk of melanoma. Krengel et al. state that this risk is highest in “garment lesions” of the trunk. Neither review showed any evidence of a positive impact of prophylactic surgery on the risk of melanoma. They explain the limitation of performing statistical analysis on a group of studies that differ from each other in description of lesion location, lesion size, and type of surgery. We are criticized for quoting the studies by Kinsler et al.3–5 These studies rely on patients who were referred by physicians to participate in the study at Great Ormond Street Hospital, one of the finest pediatric hospitals in the world, after definite diagnosis of congenital melanocytic nevus by a dermatologist. The patients provided answers to an annual questionnaire, and over 300 patients were followed for a median of 9 years. Kinsler et al. report five cases of melanoma (1.4 percent), all occurring in patients with congenital melanocytic nevi larger than 60 cm of the trunk or multiple lesions, and all with satellite lesions at birth. This is supported by studies such as the Registry of Large
Volume 134, Number 4 • Letters Congenital Melanocytic Nevi of the New York University School of Medicine that we will refer to later. Second, the letter states that our “data cannot be relied on as scientifically accurate,” because it was obtained through parent questionnaires. To be clear, these questionnaires were largely seeking factual information, such as the size of the nevus, number of satellite lesions, development of new areas of the nevus, and others. This factual information is indeed valid and, considering the size of the cohort and the length of the study, provides very worthwhile information. Features such as cosmesis or worthiness of surgery may be too subjective to be scientifically sound, but we did not infer this, nor was it the primary focus of the study. The Registry of Large Congenital Melanocytic Nevi of the New York University School of Medicine studies,6,7 coauthored by Dr. Marghoob (who by the way is a signatory to the letter criticizing our article), are also based on information obtained from physicians who initially provided the data for entering their patients into the registry. They state that “follow-up information was obtained through mailed questionnaires, telephone calls and/or email from the physicians who initially enrolled the patients into the registry, from the patients themselves, or from other relatives or caregivers.” Does this invalidate the study or its findings, as suggested by the authors of the letter? We do not think so! In fact, it provides valuable information regarding the location of the development of melanoma, with nine of the 10 patients having a congenital melanocytic nevus in the trunk and no melanomas arising in lesions of the head or extremities. Third, the letter criticizes our article for quoting articles that infer that surgery may have adverse effects on congenital melanocytic nevus cells. It is well known that these lesions change over time in their color and surface characteristics. We simply do not know what occurs to the cells when they are manipulated, either by laser, dermabrasion, or incomplete surgical excision. Nowhere in our article do we write that surgical treatment for congenital melanocytic nevus raises the risk of melanoma. To be fair, although Kinsler et al. raise concerns of possible adverse outcomes resulting from melanocytic activation by surgery, she states that she found no significant effects of having treatment, treatment timing, or type, on neurologic outcomes, tumors, melanoma, or death. It should be noted that Kinsler is a world authority in the field of congenital melanocytic nevi, her research is very highly regarded, and her opinions should be considered seriously. In the Registry of Large Congenital Melanocytic Nevi of the New York University School of Medicine series, treatment methods included complete excision (12 percent) or partial removal (46 percent) using direct closure, grafting, tissue expansion, dermabrasion, or a mix of the above procedures. They found no association between the treatment of large congenital melanocytic nevi and the development of melanoma. Marghoob et al.8 refer to the findings in this study and the Swedish birth registry sample
study.9 They explain the low incidence of melanoma in both (4.9 percent and 0 percent, respectively) by the relatively high rates of surgery (58 percent and 40 percent, respectively). However, we feel this is a difficult conclusion to draw amidst the diversity in type and extent of treatments and particularly the absence of a control group. It is emphasized in our article that we too favor surgical excision of giant congenital nevi of the trunk, because they appear to have a higher risk for melanoma. We disagree with the claim that our article “serves to spread misinformation to the lay public, which in turn creates a barrier hindering rational discussion of treatment options.” Rational discussion should be based on the understanding that some congenital melanocytic nevi have higher risks than others, and that surgery does not necessarily improve outcomes. We suggest that these unsolved issues and others pertaining to congenital melanocytic nevi be looked at in a scientifically valid, prospective, multicenter study. Our unit would welcome such a collaborative effort, as it would provide factual data in the management of our patients. Once again, we thank you for the opportunity to respond. DOI: 10.1097/PRS.0000000000000578
Ehud Arad, M.D. Ronald M. Zuker, M.D. The Hospital for Sick Children Toronto, Ontario, Canada Correspondence to Dr. Zuker The Hospital for Sick Children 555 University Avenue, Suite 1524 Toronto, Ontario, Canada M5G 1X8 [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Krengel S, Hauschild A, Schäfer T. Melanoma risk in congenital melanocytic naevi: A systematic review. Br J Dermatol. 2006;155:1–8. 2. Watt AJ, Kotsis SV, Chung KC. Risk of melanoma arising in large congenital melanocytic nevi: A systematic review. Plast Reconstr Surg. 2004;113:1968–1974. 3. Kinsler VA, Birley J, Atherton DJ. Great Ormond Street Hospital for Children Registry for congenital melanocytic naevi: Prospective study 1988-2007. Part 1: Epidemiology, phenotype and outcomes. Br J Dermatol. 2009;160:143–150. 4. Kinsler VA, Birley J, Atherton DJ. Great Ormond Street Hospital for Children Registry for Congenital Melanocytic Naevi: Prospective study 1988-2007. Part 2: Evaluation of treatments. Br J Dermatol. 2009;160:387–392. 5. Kinsler VA, Chong WK, Aylett SE, Atherton DJ. Complications of congenital melanocytic naevi in children: Analysis of 16 years’ experience and clinical practice. Br J Dermatol. 2008;159:907–914. 6. Bittencourt FV, Marghoob AA, Kopf AW, Koenig KL, Bart RS. Large congenital melanocytic nevi and the risk for
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Plastic and Reconstructive Surgery • October 2014 evelopment of malignant melanoma and neurocutaneous d melanocytosis. Pediatrics 2000;106:736–741. 7. Hale EK, Stein J, Ben-Porat L, et al. Association of melanoma and neurocutaneous melanocytosis with large congenital melanocytic naevi: Results from the NYU-LCMN registry. Br J Dermatol. 2005;152:512–517. 8. Marghoob AA, Agero AL, Benvenuto-Andrade C, Dusza SW. Large congenital melanocytic nevi, risk of cutaneous melanoma, and prophylactic surgery. J Am Acad Dermatol. 2006;54:868–870; discussion 871. 9. Berg P, Lindelöf B. Congenital nevocytic nevi: Follow-up of a Swedish birth register sample regarding etiologic factors, discomfort, and removal rate. Pediatr Dermatol. 2002;19:293–297.
Tension Shielding with the embrace Device: Does It Really Improve Scars? Sir:
D
rs. Lim et al.1 claim that the embrace device (Neodyne Biosciences, Inc., Menlo Park, Calif.) significantly decreases scarring. If true, this product represents a monumental advance. As the authors note,1 no previous treatment has been proven effective in minimizing scars. Is it time for all plastic surgeons to order this product? Although the study has a high-level design, methodologic considerations merit scrutiny.2 The investigators did not evaluate consecutive patients. There is no reported inclusion rate. These deficiencies invite selection bias.2 The authors concede that their patient
volume, only 10 patients who completed the study, is “relatively small.”1 The measuring device was qualitative. Photographic measurements of scar dimensions might have been helpful. It is risky to dismiss objective measures by saying that in the end it is the patient’s opinion that matters.1 It is hoped that we aspire to a real benefit and not just a perceived one. “Tension-shielding”1 sounds desirable. It would be useful for the authors to demonstrate that their device really does minimize wound tension. Other investigators3 have used a tensiometer to measure skin response to surface tension. There are problems with the figure legends. The legends to Figures 3, 4, and 5 all state that the above, left photographs represent preoperative photographs and the remaining photographs are all taken after revision.1 However, the appearance of the scars and adjacent skin markings reveal that the photographs depict the same scar. If only 10 patients are being evaluated, the methodology needs to be pristine. Photographs given to a panel for evaluation must be standardized, including identical lighting and the same degree of magnification, to make the comparison a fair one. Unfortunately, this is not the case. The control scar appears wider than the embracetreated scar in Figure 4. However, this untreated scar is also magnified much more than the embrace-treated scar, as revealed by skin markings (Fig. 1). The exposure is also darker for the control scar. In Figure 5, a pigmented skin lesion disappears in a postoperative
Fig. 1. The authors’ Figure 4 is depicted. The individual photograph of the control scar (center, left) has been magnified by a factor of 7.7 compared with the photograph depicting both scars (above, left). The exposure is also darker. The individual photograph of the embrace-treated scar (center, right) is enlarged by a factor of 2.1. This difference makes the control scar appear much larger than the embrace-treated scar. Skin markings are used for reference. The units are calibrated based on a 5-cm width of the partially visible treatment identifying marker. The units are arbitrary. (Adapted with permission from Lim AF, Weintraub J, Kaplan EN, et al. The embrace device significantly decreases scarring following scar revision surgery in a randomized controlled trial. Plast Reconstr Surg. 2014;133:398–405.)
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Bruce S. Bauer M.D. Sara R. Dickie, M.D. Ashfaq A. Marghoob, M.D. Division of Plastic and Reconstructive Surgery NorthShore University HealthSystem Northbrook, Ill. Correspondence to Dr. Dickie Division of Plastic and Reconstructive Surgery NorthShore University HealthSystem 501 Skokie Boulevard, Suite 250 Northbrook, Ill. 60062 [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Arad E, Zuker RM. The shifting paradigm in the management of giant congenital melanocytic nevi: Review and clinical applications. Plast Reconstr Surg. 2014;133:367–376.
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2. Krengel S, Hauschild A, Schäfer T. Melanoma risk in congenital melanocytic naevi: A systematic review. Br J Dermatol. 2006;155:1–8. 3. Kinsler VA, Birley J, Atherton DJ. Great Ormond Street Hospital for Children Registry for Congenital Melanocytic Naevi: Prospective study 1988-2007. Part 2—Evaluation of treatments. Br J Dermatol. 2009;160:387–392.
Reply: The Shifting Paradigm in the Management of Giant Congenital Melanocytic Nevi: Review and Clinical Applications Sir:
Thank you for allowing us to respond to the letter addressing our article. We are actually quite impressed that the article has generated such interest and underscores its importance. The letter is written by authorities in the field of congenital melanocytic nevi and needs to be heard. We are pleased to respond. First, the authors claim that we base our current treatment philosophy on the opinion of one institution and one clinician. Our treatment algorithm is in fact based on data from several studies and several institutions, including our own. We conclude the following: 1. The risk of melanoma in patients with giant congenital melanocytic nevi is generally higher than in the general population (0.7 to 2.9 percent versus 0.6 percent). 2. Patients with giant congenital melanocytic nevi of the trunk or multiple satellite lesions have the highest risk and may account for most of the elevated risks mentioned (patients with lesions of the head and extremities run a low risk). 3. There is no proof that surgery lowers the risk for melanoma. We quoted two systematic reviews, by Krengel et al.1 and by Watt et al.2 Both reviews demonstrate an association between large lesion size and high risk of melanoma. Krengel et al. state that this risk is highest in “garment lesions” of the trunk. Neither review showed any evidence of a positive impact of prophylactic surgery on the risk of melanoma. They explain the limitation of performing statistical analysis on a group of studies that differ from each other in description of lesion location, lesion size, and type of surgery. We are criticized for quoting the studies by Kinsler et al.3–5 These studies rely on patients who were referred by physicians to participate in the study at Great Ormond Street Hospital, one of the finest pediatric hospitals in the world, after definite diagnosis of congenital melanocytic nevus by a dermatologist. The patients provided answers to an annual questionnaire, and over 300 patients were followed for a median of 9 years. Kinsler et al. report five cases of melanoma (1.4 percent), all occurring in patients with congenital melanocytic nevi larger than 60 cm of the trunk or multiple lesions, and all with satellite lesions at birth. This is supported by studies such as the Registry of Large
Volume 134, Number 4 • Letters Congenital Melanocytic Nevi of the New York University School of Medicine that we will refer to later. Second, the letter states that our “data cannot be relied on as scientifically accurate,” because it was obtained through parent questionnaires. To be clear, these questionnaires were largely seeking factual information, such as the size of the nevus, number of satellite lesions, development of new areas of the nevus, and others. This factual information is indeed valid and, considering the size of the cohort and the length of the study, provides very worthwhile information. Features such as cosmesis or worthiness of surgery may be too subjective to be scientifically sound, but we did not infer this, nor was it the primary focus of the study. The Registry of Large Congenital Melanocytic Nevi of the New York University School of Medicine studies,6,7 coauthored by Dr. Marghoob (who by the way is a signatory to the letter criticizing our article), are also based on information obtained from physicians who initially provided the data for entering their patients into the registry. They state that “follow-up information was obtained through mailed questionnaires, telephone calls and/or email from the physicians who initially enrolled the patients into the registry, from the patients themselves, or from other relatives or caregivers.” Does this invalidate the study or its findings, as suggested by the authors of the letter? We do not think so! In fact, it provides valuable information regarding the location of the development of melanoma, with nine of the 10 patients having a congenital melanocytic nevus in the trunk and no melanomas arising in lesions of the head or extremities. Third, the letter criticizes our article for quoting articles that infer that surgery may have adverse effects on congenital melanocytic nevus cells. It is well known that these lesions change over time in their color and surface characteristics. We simply do not know what occurs to the cells when they are manipulated, either by laser, dermabrasion, or incomplete surgical excision. Nowhere in our article do we write that surgical treatment for congenital melanocytic nevus raises the risk of melanoma. To be fair, although Kinsler et al. raise concerns of possible adverse outcomes resulting from melanocytic activation by surgery, she states that she found no significant effects of having treatment, treatment timing, or type, on neurologic outcomes, tumors, melanoma, or death. It should be noted that Kinsler is a world authority in the field of congenital melanocytic nevi, her research is very highly regarded, and her opinions should be considered seriously. In the Registry of Large Congenital Melanocytic Nevi of the New York University School of Medicine series, treatment methods included complete excision (12 percent) or partial removal (46 percent) using direct closure, grafting, tissue expansion, dermabrasion, or a mix of the above procedures. They found no association between the treatment of large congenital melanocytic nevi and the development of melanoma. Marghoob et al.8 refer to the findings in this study and the Swedish birth registry sample
study.9 They explain the low incidence of melanoma in both (4.9 percent and 0 percent, respectively) by the relatively high rates of surgery (58 percent and 40 percent, respectively). However, we feel this is a difficult conclusion to draw amidst the diversity in type and extent of treatments and particularly the absence of a control group. It is emphasized in our article that we too favor surgical excision of giant congenital nevi of the trunk, because they appear to have a higher risk for melanoma. We disagree with the claim that our article “serves to spread misinformation to the lay public, which in turn creates a barrier hindering rational discussion of treatment options.” Rational discussion should be based on the understanding that some congenital melanocytic nevi have higher risks than others, and that surgery does not necessarily improve outcomes. We suggest that these unsolved issues and others pertaining to congenital melanocytic nevi be looked at in a scientifically valid, prospective, multicenter study. Our unit would welcome such a collaborative effort, as it would provide factual data in the management of our patients. Once again, we thank you for the opportunity to respond. DOI: 10.1097/PRS.0000000000000578
Ehud Arad, M.D. Ronald M. Zuker, M.D. The Hospital for Sick Children Toronto, Ontario, Canada Correspondence to Dr. Zuker The Hospital for Sick Children 555 University Avenue, Suite 1524 Toronto, Ontario, Canada M5G 1X8 [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Krengel S, Hauschild A, Schäfer T. Melanoma risk in congenital melanocytic naevi: A systematic review. Br J Dermatol. 2006;155:1–8. 2. Watt AJ, Kotsis SV, Chung KC. Risk of melanoma arising in large congenital melanocytic nevi: A systematic review. Plast Reconstr Surg. 2004;113:1968–1974. 3. Kinsler VA, Birley J, Atherton DJ. Great Ormond Street Hospital for Children Registry for congenital melanocytic naevi: Prospective study 1988-2007. Part 1: Epidemiology, phenotype and outcomes. Br J Dermatol. 2009;160:143–150. 4. Kinsler VA, Birley J, Atherton DJ. Great Ormond Street Hospital for Children Registry for Congenital Melanocytic Naevi: Prospective study 1988-2007. Part 2: Evaluation of treatments. Br J Dermatol. 2009;160:387–392. 5. Kinsler VA, Chong WK, Aylett SE, Atherton DJ. Complications of congenital melanocytic naevi in children: Analysis of 16 years’ experience and clinical practice. Br J Dermatol. 2008;159:907–914. 6. Bittencourt FV, Marghoob AA, Kopf AW, Koenig KL, Bart RS. Large congenital melanocytic nevi and the risk for
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Plastic and Reconstructive Surgery • October 2014 evelopment of malignant melanoma and neurocutaneous d melanocytosis. Pediatrics 2000;106:736–741. 7. Hale EK, Stein J, Ben-Porat L, et al. Association of melanoma and neurocutaneous melanocytosis with large congenital melanocytic naevi: Results from the NYU-LCMN registry. Br J Dermatol. 2005;152:512–517. 8. Marghoob AA, Agero AL, Benvenuto-Andrade C, Dusza SW. Large congenital melanocytic nevi, risk of cutaneous melanoma, and prophylactic surgery. J Am Acad Dermatol. 2006;54:868–870; discussion 871. 9. Berg P, Lindelöf B. Congenital nevocytic nevi: Follow-up of a Swedish birth register sample regarding etiologic factors, discomfort, and removal rate. Pediatr Dermatol. 2002;19:293–297.
Tension Shielding with the embrace Device: Does It Really Improve Scars? Sir:
D
rs. Lim et al.1 claim that the embrace device (Neodyne Biosciences, Inc., Menlo Park, Calif.) significantly decreases scarring. If true, this product represents a monumental advance. As the authors note,1 no previous treatment has been proven effective in minimizing scars. Is it time for all plastic surgeons to order this product? Although the study has a high-level design, methodologic considerations merit scrutiny.2 The investigators did not evaluate consecutive patients. There is no reported inclusion rate. These deficiencies invite selection bias.2 The authors concede that their patient
volume, only 10 patients who completed the study, is “relatively small.”1 The measuring device was qualitative. Photographic measurements of scar dimensions might have been helpful. It is risky to dismiss objective measures by saying that in the end it is the patient’s opinion that matters.1 It is hoped that we aspire to a real benefit and not just a perceived one. “Tension-shielding”1 sounds desirable. It would be useful for the authors to demonstrate that their device really does minimize wound tension. Other investigators3 have used a tensiometer to measure skin response to surface tension. There are problems with the figure legends. The legends to Figures 3, 4, and 5 all state that the above, left photographs represent preoperative photographs and the remaining photographs are all taken after revision.1 However, the appearance of the scars and adjacent skin markings reveal that the photographs depict the same scar. If only 10 patients are being evaluated, the methodology needs to be pristine. Photographs given to a panel for evaluation must be standardized, including identical lighting and the same degree of magnification, to make the comparison a fair one. Unfortunately, this is not the case. The control scar appears wider than the embracetreated scar in Figure 4. However, this untreated scar is also magnified much more than the embrace-treated scar, as revealed by skin markings (Fig. 1). The exposure is also darker for the control scar. In Figure 5, a pigmented skin lesion disappears in a postoperative
Fig. 1. The authors’ Figure 4 is depicted. The individual photograph of the control scar (center, left) has been magnified by a factor of 7.7 compared with the photograph depicting both scars (above, left). The exposure is also darker. The individual photograph of the embrace-treated scar (center, right) is enlarged by a factor of 2.1. This difference makes the control scar appear much larger than the embrace-treated scar. Skin markings are used for reference. The units are calibrated based on a 5-cm width of the partially visible treatment identifying marker. The units are arbitrary. (Adapted with permission from Lim AF, Weintraub J, Kaplan EN, et al. The embrace device significantly decreases scarring following scar revision surgery in a randomized controlled trial. Plast Reconstr Surg. 2014;133:398–405.)
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