The approach presented is, we believe, the first use of an expanded pocket to reconstruct a circumferential congenital pigmented nevus of the arm. This approach combines the basic plastic surgical principle of a delayed pocket flap with minimally invasive endoscopic dissection and the benefits of tissue expansion to provide a safe and versatile approach to reconstruct a traditionally difficult problem.

The reconstruction of congenital pigmented nevi (CPN) of the extremity is usually addressed with staged excision, expanded adjacent tissue transfer, skin grafts (with or without expansion) or some combination of the above. When these lesions are circumferential the reconstructive options are severely limited. Adjacent tissue expansion is complicated by the absence of unaffected adjacent tissue, the limitations of axial expansion and the difficulty with pediatric tissue expansion in the extremities in general. Skin grafts provide adequate coverage, however, the aesthetic result is usually less than desired and there may be long-term difficulties with scarring and contraction. These limitations can be improved with the use of expanded full-thickness skin grafts, but the contour deformity and color differences often remain and functional issues from scarring are still a potential problem.

The technique reported here demonstrates the ability to excise a large circumferential CPN of the extremity and reconstruct the wound with skin that is supple and has the same color, contour, and texture as the normal skin. Creating an expanded flank/abdominal “pocket” is the first stage. The tissue expander is placed using minimally invasive endoscopic dissection and is expanded over a few months. The second stage involves removing the tissue expander and placing the denuded arm in this “pocket” as a delayed type flap. It should be noted that arm is placed under the capsule of the expander, not merely in the subcutaneous tissue. The third stage involves the final inset of the expanded flap and primary closure of the donor defect. In the case presented, the CPN on the dorsum of the hand was excised and reconstructed in a single step with Apligraf. The CPN on the upper arm and elbow was excised and reconstructed utilizing local expanded adjacent tissue transfer.

Conclusion

The procedure described attempts to achieve many of the principles employed in the reconstructive pursuits of plastic surgeons. These principles include: reconstruction of the defect with like tissue, utilizing minimally invasive techniques, and minimal donor site morbidity which is especially important in children. Furthermore, this procedure places another option to be added to our reconstructive armamentarium, in our quest to continue to improve our knowledge and skill as plastic surgeons.