Removing large birthmarks and scars with Serial Excision
04 February 2019
When a baby is born with a large birthmark in a very obvious place, it is natural for parents to feel afraid for their child and the future. This is the story of a child I began to operate on almost eighteen years ago.
At the beginning of 2001, an eight week old baby girl was brought along to see me by her parents. She was born with a very large black/brown birthmark, known as a congenital melanocytic naevus, measuring 3.5cm x 4.5cm covering almost all of one side of her forehead. A lesion almost 16 square centimetres in area is large even for an adult, and the mark would enlarge in area as she grew. I discussed with her parents a variety of options for treating the birthmark, including dermabrasion, removal with a laser, tissue expansion using a balloon under the skin and skin grafting. I also put to them a further alternative, to cut out the centre of the lesion over a series of procedures over several years to gradually excise the majority of the lesion. As I wrote to the GP at the time, mother and father had a lot to think through before making any decisions. Four months later, I undertook the first procedure.
Throughout the treatment process, the parents were unwaveringly supportive of their child, myself and the staff at the hospital. They kept in touch, letting us know how she was doing, and five years ago, they sent the following message:
"You may remember our daughter who was born with a melanocytic naevus on her forehead in 2001? We first came to see you when she was 8 weeks old and you performed seven serial excision operations on her over a period of a few years. She had her 13th birthday last week! We can't believe how time has flown and how our beautiful baby has grown into a gorgeous (if hormonal!) teenager. We think of you often and remain eternally grateful for your skill and expertise, at a time when it seemed that no one else was able to help. She is sociable, outgoing and confident - something we feared may never have been possible for her."
Five more years have passed and the baby girl has become a lovely and confident young woman, in no small measure due to her parents' level-headed approach from the outset to the problems her naevus might present . Her own stout-heartedness in allowing her photos to be shown publicly has helped many others greatly in finding options for their birthmarks.
Whilst laser ablation can be useful for some pigmented skin blemishes, the pigment in some very dark birthmarks goes very deeply through the layers of the skin, and is out of reach of the safe powers of laser or light treatment. For other pigmented marks, such as café-au-lait marks (tea stains), the unwanted discolouration can be completely removed, only to come back sometimes years later after some particularly strong sunshine. Serial excision has neither of these problems. Very young children can be thought of as wearing a slightly baggy suit of skin, that is, the envelope of skin which covers them is too big, to allow for the rapid growth that occurs in childhood. It is well-known that surgery at an early age can have very good results because of the ability of the tissues to remodel at a very fast rate. This must be balanced against the undoubted risks of general anaesthesia, especially under two years of age, and a surgeon's choice of an anaesthetist with skill and experience in this age group is paramount in this equation. For birthmarks which are very obvious at a social distance, however, serial excision can give worthwhile results.
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