Medicine: Growing an Extra Skin
Hadassah Hospital is helping children with a disfiguring dermatological condition through a series of innovative and fascinating surgical procedures.
We may diplomatically refer to them as beauty marks, but a mole by any other name is still clearly a mole. Raised or flat, dark brown or bluish black, these skin lesions are not only unsightly but can also herald a virulent skin cancer. For reasons of health or beauty, many of us born with moles will go to a plastic surgeon to have the pigmented cells scooped out.
With almost all of these moles measuring less than a quarter-inch in diameter, their removal usually takes no more than five minutes under a local anesthetic with the excision leaving scarcely a scar.
But moles can come far bigger than these modest blotches. A little boy, now being treated at the Hadassah–Hebrew University Medical Center at Ein Kerem, was born with “what looked like a big black cat sitting on his head,” according to Dr. Alex Margulis, assistant professor of plastic and reconstructive surgery at Hadassah and head of its Pediatric Plastic Surgery Service. “Half his scalp was covered with a raised hairy black mole,” he says. “His fraternal twin was unmarked.”
These relatively uncommon giant congenital moles, or nevi, more often appear on the body than the head. Bathing-trunk nevi envelop the body from above the waist down to the knees. But, smooth or warty, nevi can also blanket the arms, legs, face, hands, feet and scalp.
“Their cause is unknown,” explains Dr. Margulis. “It is believed the overgrowth of specific types of skin cell that result in nevi is a consequence of spontaneous mutation during fetal development, although the frequent appearance of these lesions in some families suggests that genetics may be involved, too. What is known is that nevi carry up to an 8-percent risk of malignant melanoma—as well as a crushing emotional burden. Their removal is therefore a matter of great urgency.”
Until about 10 to 15 years ago, however, removing giant nevi was highly problematic. “While small moles can be excised on an outpatient basis, a stitch or two to close up the gap, the cutting away of giant nevi leaves a huge open wound,” says Dr. Margulis. “In some patients, this wound would extend over half the body’s surface. Neither bandages nor donor skin can ensure healing or defend against infection. So this is not a treatment option.”
Late last year, however, three years after he established Hadassah’s Pediatric Plastic Surgery Service, Dr. Margulis successfully removed the 100th giant nevus from the 100th youngster to turn to Hadassah Hospital. He replaced the pigmented tissue with healthy pink skin, and by the time treatment is complete, there will be practically no mark to show for it.
Excision of giant moles has become possible because doctors can now grow replacement skin on the patients themselves. “We insert small silicone balloons under healthy skin adjacent to the nevus and slowly inflate these balloons over a period of months,” explains Dr. Margulis. “The skin above them expands in the same way as that on a woman’s stomach during pregnancy. When we remove the balloons, there is spare tissue with which to cover the area from where we excise the nevus.”
This replacement skin enables doctors to repair disfiguring skin conditions without scarring. “Our aim is not only to remove the defect but also to achieve a good cosmetic result,” says Dr. Margulis, who spent three years training in pediatric plastic surgery at the Children’s Memorial Hospital, Northwestern University’s Feinberg School of Medicine, in Chicago and brought the specialty back to Hadassah.
While the basic idea is simple—expand the skin over the wound and neatly stitch it down—its implementation is varied and must often be highly creative.
“Sometimes, particularly with bathing-trunk nevi, the birthmark is so extensive that we must excise it in stages,” says Dr. Margulis. “We’re now toward the end of treating a little boy, born with a pigmented nevus stretching from his waist to his left knee. Starting at the top of his birthmark, we worked our way down. We recently performed his fourth surgical procedure in which we removed two silicone expanders from beneath the skin, excised the final quarter of the nevus and covered it up with this specially grown skin. The child is now 3 years old, and we’ve been treating him for most of his life.”
“He was my first baby,” says the little boy’s mother. “I spent his first weeks weeping about the grotesque black mole that covered him. At the beginning it was all so hard—seeing him look misshapen as the under-skin balloons expanded, not really having faith that Dr. Margulis could deliver on his promises.
“But after the first part of the mole was removed when he was 5 months old,” she adds, “my husband and I knew the Hadassah team would succeed.”
The key to a good aesthetic result, according to Dr. Margulis, is the planning—where to place the skin-expanders, how much of the nevus to remove each time, how and where to stitch the expanded skin and what kind of skin to expand. The skin grown to replace the nevus on the scalp of the newborn twin, for example, will be hair-bearing skin from the other side of the child’s head. Two large balloons are currently under this healthy skin.
“Our baby is very young and unbothered by either the mole or the expanders,” says his father. “But for my wife and me, it’s a very hard time. We don’t understand why this has happened to us. The mole is monstrous, and now that the expanders are pushing out two huge lumps on the healthy side of his head, he looks horrifically deformed. We know from Dr. Margulis and the social worker that within months our baby will look as normal as his brother—but these are long months indeed.”
While this infant’s treatment will take months, a 2-year-old girl from Nahariya in northern Israel spent two weeks in an unusual situation.
“The child’s hand and lower arm were disfigured by a dark brown mole,” says Dr. Margulis. “Because it would have taken a long time and a large number of procedures to expand sufficient skin on her slender arm to replace all that we needed to excise, we chose instead to put an expander under the skin of her stomach. When we had sufficient tissue there, we excised the nevus from the limb and sewed the child’s hand and lower arm into the flap of skin on her stomach for two weeks. She coped with having her hand attached to her stomach very well. Within a couple of weeks, once the new skin took root on her hand and arm, we cut the arm free.”
While silicone expanders have been used in reconstructive surgery for some time, the procedure has been taken to a new level of expertise at Hadassah. “We’re the most experienced team in Israel in this technique,” recounts Dr. Margulis. “Patients come to us from outside Israel as well, although they tend to come for reconstructive surgery after severe burns rather than removal of nevi.”
A 4-year-old boy from cyprus whose scalp and ear were burned on one side when he was trapped inside a blazing car traveled back and forth from Nicosia to Hadassah for treatment.
“We put expanders under the skin on the undamaged part of the child’s scalp and replaced the excessively scarred tissue in four separate procedures,” explains Dr. Margulis. “That treatment is now complete, and hair is growing all over his head again. Still ahead is reconstructing of the child’s burned ear out of cartilage from his chest.”
The 30 to 40 annual procedures to excise giant nevi constitute only part of the work of Hadassah’s Pediatric Plastic Surgery Service. In another 360 children each year, surgeons graft bone to repair cleft palates, sculpt ears or noses, hook eyelids to eyebrows to circumvent droopy eyes, excise congenital tumors, minimize the damage done by traumatic injuries and—not uncommonly—repair procedures performed at other hospitals.
Most of the young patients cope admirably with the treatments, according to Dr. Margulis. (The majority of patients are under 10; skin expansion can be used on adults, however, skin tissue becomes less elastic with aging, and the procedure is correspondingly less effective.)
“I recently removed a giant nevus from the back of a 7-year-old girl,” Dr. Margulis says. “She was a hospital veteran, having been unsuccessfully treated elsewhere. Her treatment at Hadassah was lengthy: overnight hospitalization to insert two expanders in her back; overnight hospitalization some months later to remove them; excision of half the nevus and stitching down the new skin; and then a repeat for the second half, this time with the expanders in her buttocks. She was cheerful and cooperative throughout.”
Recognizing the emotional strain imposed by giant nevi and their removal on the parents if not the patients, Hadassah has established what it calls its Nevus Family. A support group guided by Pediatric Plastic Surgery Service physicians and social workers, it offers medical and nonmedical information and help as well as an annual party for all its members.
Successful though the treatment is, Dr. Margulis and his team look ahead to a time when their surgical experience will be redundant in removing unsightly nevi.
We hope to develop a nonsurgical treatment—an ointment or drugs,” he says. “We’re taking cells from the nevi we excise, growing them in a special culture and attacking them with different cell-destroying agents.”
This research is both unique and promising. Hadassah has the only team worldwide that has succeeded in growing nevi cells, and some of the chemotherapeutic agents that they are testing are producing good results.
Until giant moles can be pharmaceutically destroyed, however, skilled pediatric plastic surgeons, such as the team at Hadassah, are the only answer for those unfortunate people blemished by their very unbeautiful beauty marks.