The clinical evolution of a kissing naevus after incomplete excision
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《英国眼科学杂志》
1 Massachusetts Eye and Ear Infirmary, Harvard Medical School, Ophthalmic Plastic, Orbital and Cosmetic Surgery, 243 Charles Street, Boston, MA, USA
2 Lankanau Hospital, Thomas Jefferson University, 100 Lancaster Avenue, Wynnewood, PA19096, USA
3 Emory Eye Center, Emory University School of Medicine, 1365 B Clifton Road, NE, Atlanta, GA, USA
Correspondence to:
C Robert Bernardino MD
Emory Eye Center, Oculoplastics and Orbital Surgery, 1365B Clifton Road, NE, Atlanta, GA 30322, USA; crbernardino@mac.com
Accepted for publication 25 November 2003
Keywords: eyelid; naevus; reconstruction
We present an interesting case of a kissing naevus which was not completely excised during the patient’s childhood, 29 years before presentation.
Case report
A 33 year old white man complained of progressive thickening of the eyelids which caused significant inferior visual field defect with downgaze (fig 1). A large, circumorbital pigmented naevus in the right eye had been present since birth. There was minimal growth through early childhood. This mass did not cause ptosis nor was it amblyogenic.
Figure 1 Clinical appearance of the patient at age 33 years. A verrucous thickening caused right upper lid ptosis and lower lid thickness, compromising the inferior visual field. Surrounding hypopigmentation was an area of previous reconstruction. The lateral aspect of the eyebrow is an appliqué.
At 4 years of age he had excision of the naevus of the right lower eyelid with reconstruction with a split thickness skin graft (fig 2). Of significance, he had incomplete excision of a kissing naevus from his eyelids as a child. At age 6 a similar procedure was performed to address the upper eyelid and brow. The margin of the upper eyelid also had residual pigmentation.
Figure 2 A photomontage of the appearance of the circumorbital naevus throughout childhood. (1) 6 months of age, (2) 4 years of age, (3) after excision from lower eyelid at age 4, (4) after excision from upper eyelid at age 6. Note the residual pigmentation of lid margin in (3) and (4).
When he was aged 33, we performed a biopsy to rule out malignant changes; the biopsy confirmed a diagnosis of dermal naevus. Subsequently, a complete excision of the mass from the right lower eyelid and reconstruction with a full thickness skin graft was performed.
Comment
A kissing naevus is a type of congenital compound naevus that affects equal portions of the upper and lower eyelid. Owing to its extension to the lid margins, the edges of the tumour touch or "kiss" during closure of the lids.1 The kissing naevus origin dates to melanocyte migration during the embryological fusion of the lids at the ninth week of gestation, producing the "kissing" or split naevus.2
Congenital naevi occur in approximately 1% of all newborns, with the vast majority being less than 1.5 cm in size.3 Compound naevi possess features of junctional (arising from the deeper layers of the epidermis or "junctional region") and intradermal naevi. The lifetime risk of malignant degeneration in small congenital naevi is not clearly established. Large cutaneous melanocytic naevi (more than 4 cm), however, do give rise to melanoma.4 The risk of malignant transformation is 4.6% during a 30 year period.5
Kissing naevi of the eyelids may be cosmetically objectionable and cause functional problems including ptosis and visual field defects. Management usually requires surgical excision and reconstruction with split or full thickness skin grafts. Initial, complete excision is important because residual tumour can grow, often with a more verrucous or thickened appearance making subsequent determination of malignant transformation and reconstruction challenging.
References
Mcdonnell PJ, Mayou BJ. Congenital divided naevus of the eyelids. Br J Ophthalmol 1988;72:198–201.
Westfall CT, Shore JW, Rubin PA, et al. Kissing nevus masquerading as a viral papilloma. Ophthalmic Surg 1991;22:614–15.
National Cancer Institute. Concensus conference—precursors to malignant melanoma. JAMA 1984;251:1864–66.
Margo CE, Rabinowicz IM, Habal MB. Periocular congenital melanocytic nevi. JPOS 1986;23:222–6.
Lorentzen M, Pers M, Bretteville-Jensen G. The incidence of malignant transformation in giant pigmented nevi. Scand J Plast Reconstr Surg 1977;11:163–7.(W Y Wu-Chen1,2, C R Berna)
2 Lankanau Hospital, Thomas Jefferson University, 100 Lancaster Avenue, Wynnewood, PA19096, USA
3 Emory Eye Center, Emory University School of Medicine, 1365 B Clifton Road, NE, Atlanta, GA, USA
Correspondence to:
C Robert Bernardino MD
Emory Eye Center, Oculoplastics and Orbital Surgery, 1365B Clifton Road, NE, Atlanta, GA 30322, USA; crbernardino@mac.com
Accepted for publication 25 November 2003
Keywords: eyelid; naevus; reconstruction
We present an interesting case of a kissing naevus which was not completely excised during the patient’s childhood, 29 years before presentation.
Case report
A 33 year old white man complained of progressive thickening of the eyelids which caused significant inferior visual field defect with downgaze (fig 1). A large, circumorbital pigmented naevus in the right eye had been present since birth. There was minimal growth through early childhood. This mass did not cause ptosis nor was it amblyogenic.
Figure 1 Clinical appearance of the patient at age 33 years. A verrucous thickening caused right upper lid ptosis and lower lid thickness, compromising the inferior visual field. Surrounding hypopigmentation was an area of previous reconstruction. The lateral aspect of the eyebrow is an appliqué.
At 4 years of age he had excision of the naevus of the right lower eyelid with reconstruction with a split thickness skin graft (fig 2). Of significance, he had incomplete excision of a kissing naevus from his eyelids as a child. At age 6 a similar procedure was performed to address the upper eyelid and brow. The margin of the upper eyelid also had residual pigmentation.
Figure 2 A photomontage of the appearance of the circumorbital naevus throughout childhood. (1) 6 months of age, (2) 4 years of age, (3) after excision from lower eyelid at age 4, (4) after excision from upper eyelid at age 6. Note the residual pigmentation of lid margin in (3) and (4).
When he was aged 33, we performed a biopsy to rule out malignant changes; the biopsy confirmed a diagnosis of dermal naevus. Subsequently, a complete excision of the mass from the right lower eyelid and reconstruction with a full thickness skin graft was performed.
Comment
A kissing naevus is a type of congenital compound naevus that affects equal portions of the upper and lower eyelid. Owing to its extension to the lid margins, the edges of the tumour touch or "kiss" during closure of the lids.1 The kissing naevus origin dates to melanocyte migration during the embryological fusion of the lids at the ninth week of gestation, producing the "kissing" or split naevus.2
Congenital naevi occur in approximately 1% of all newborns, with the vast majority being less than 1.5 cm in size.3 Compound naevi possess features of junctional (arising from the deeper layers of the epidermis or "junctional region") and intradermal naevi. The lifetime risk of malignant degeneration in small congenital naevi is not clearly established. Large cutaneous melanocytic naevi (more than 4 cm), however, do give rise to melanoma.4 The risk of malignant transformation is 4.6% during a 30 year period.5
Kissing naevi of the eyelids may be cosmetically objectionable and cause functional problems including ptosis and visual field defects. Management usually requires surgical excision and reconstruction with split or full thickness skin grafts. Initial, complete excision is important because residual tumour can grow, often with a more verrucous or thickened appearance making subsequent determination of malignant transformation and reconstruction challenging.
References
Mcdonnell PJ, Mayou BJ. Congenital divided naevus of the eyelids. Br J Ophthalmol 1988;72:198–201.
Westfall CT, Shore JW, Rubin PA, et al. Kissing nevus masquerading as a viral papilloma. Ophthalmic Surg 1991;22:614–15.
National Cancer Institute. Concensus conference—precursors to malignant melanoma. JAMA 1984;251:1864–66.
Margo CE, Rabinowicz IM, Habal MB. Periocular congenital melanocytic nevi. JPOS 1986;23:222–6.
Lorentzen M, Pers M, Bretteville-Jensen G. The incidence of malignant transformation in giant pigmented nevi. Scand J Plast Reconstr Surg 1977;11:163–7.(W Y Wu-Chen1,2, C R Berna)