Reconstruction of the Congenital Divided Nevus of the Eyelids and Proposal of New Classification

Abstract

Background: Divided nevus is a rare form of congenital nevus that usually occurs on both upper and lower eyelids of one eye, forming one large nevus when the eyelids are closed. Typically, congenital melanocytic nevi of the body are classified according to their size (small < 1.5 cm, medium 1.5-20 cm, and large > 20 cm). However, because divided nevus of the eyelids is usually relatively small, this classification may be too coarse and not adequate. Furthermore, there is no practical classification for divided nevus of eyelids yet.

Methods: We treated 3 cases of medium and large congenital divided nevus of the eyelids using local flaps based on the idea of esthetic subunits. Also, we proposed a new classification especially for congenital divided nevus of the eyelids based on the idea of esthetic subunits.

Results: All patients were treated successfully with the reconstructive idea of esthetic subunits for the eyelids. Case 1 (medium size) was reconstructed by orbicularis musculocutaneous flap and case 2 (large size) was reconstructed by expanded flap, and case 3 (medium size) was treated by modified V-Y orbicularis oculi musculocutaneous flap. In all cases, the flap color and texture were well matched and satisfactory results were obtained. Also, by using the new classification, we were able to plan practical scheme for divided nevus reconstruction.

Conclusions: The use of our proposed classification and esthetic subunits for the divided nevus of the eyelids allows systematic surgical planning, leading to improved reconstructive outcomes.

Fig. 1.

Preoperative view of the patient (6 year old) with right divided nevus of the eyelid.

Fig. 2.

New esthetic subunits and classification for Divided Nevus of the Eyelids. A, Combination of traditional esthetic units of the face and new esthetic subunits 3A′ and 3B′, especially for divided nevus of the eyelids. B, Illustration of the proposed esthetic subunits for divided nevus of the eyelids. Orange area represents class 1 (small): 3A′, lower ciliary margin to lower eyelid crease, and 3B′, upper ciliary margin to upper eyelid crease. Yellow area represents class 2 (medium): 3A, lower eyelid crease to lower eyelid cheek junction, and 3B, upper eyelid crease to eyebrow, 3C, lateral canthus, and 3D, medial canthus. Beige area represents class 3 (large): 1–7, including eyebrow, forehead, nose, cheek, lips and chin.

Fig. 3.

Intraoperative view of Case 1. A, Resection of the upper eyelid lesion and the resulting defect. Arrows present the direction of flap movements. B, A flap from the medial canthus was transposed for reconstruction of the esthetic unit from the upper ciliary margin to the upper eyelid crease. C, A flap from the lateral canthus was advanced for reconstruction of the esthetic unit from the upper eyelid crease to the eyebrow. D, The defect extending from the lower ciliary margin to the lower eyelid crease was replaced by a lateral cheek flap.

Fig. 4.

Three-year postoperative view of the patient. A, Eyes open. B, Eyes closed.

Fig. 5.

Intraoperative view of Case 2. A, Preoperative view of the patient (9 year old) with a large-sized congenital divided nevus of the left eyelid, the left eyebrow, and the left cheek. B, Intraoperative view. A tissue expander was placed under the subcutaneous tissue of the preauricular area and above the superficial musculo-aponeurotic system. Intraoperative view of (C) lesion resection and (D) flap elevation using the sideburn to reconstruct the eyebrow at the same time.

Fig. 6.

Six-year postoperative view of the patient. A, Eyes open. B, Eyes closed.

Fig. 7.

Pre- and Intra-operative view of Case 3. A, Preoperative view of the patient (57 year old) with right divided nevus of the eyelid. B, Intraoperative view. Resection of the nevus and the resulting defect. C, A modified V-Y orbicularis oculi musculocutaneous flap was advanced to reconstruct both upper and lower eyelids and the lateral canthus. Also, the upper and the lower eyelid creases were reconstructed simultaneously.

Fig. 8.

Pre- and post-operative view of Case. A, Preoperative view of the patient. B and C, Five-year postoperative view of the patient.

Fig. 9.

A, The classification of Yap and Earley of the divided nevus. B, Traditional esthetic units of the face.