Novel management of scarred recurrent intradermal nevus on the nasal tip through tri-lobe flap and scar resurfacing

INTRODUCTION

Incomplete removal of nevi often leads to recurrence, requiring revision and scar treatment. With the increasing frequency of such procedures, often performed by non-physicians, new strategies are needed to improve scar outcomes, particularly in challenging areas such as the nasal tip. The rise in inappropriate initial treatments has led to an increase in complex cases requiring specialized reconstructive approaches, highlighting the need for educational case reports that demonstrate optimal management strategies.

We present a patient who underwent multiple inappropriate nevus removal treatments, resulting in hypertrophic scarring and recurrence, prompting her to seek specialized care for definitive management. A surgical technique traditionally employed in Mohs surgery was used innovatively to address prior scarring. This case illustrates the importance of selecting the proper initial treatment and demonstrates how surgical reconstruction, combined with adjunctive therapies, can achieve excellent outcomes even in challenging revision cases.

CASE REPORT

A 36-year-old female presented with a recurrent intradermal nevus on the left nasal supra-tip [Figure 1a] after multiple unsuccessful treatments, including shave removal, hyfrecation, and various laser modalities such as erbium and carbon dioxide (CO₂) lasers. Examination revealed a 1.6 × 2.0 cm hypopigmented plaque, and ultrasound confirmed the presence of residual nevus tissue with extensive fibrosis [Figure 2]. The patient had previously undergone Erbium and fractional CO₂ laser treatment, which failed to improve the underlying pathology and likely contributed to the hypopigmentation. Given the lesion’s size and location, an excision with a trilobe transposition flap was performed [Figure 3]. This technique, commonly used in Mohs micrographic surgery, effectively restores the nasal bridge and tip, minimizing the risk of asymmetry and contour deformity. The defect was closed with 4-0 Monocryl dermal sutures and 6-0 Ethilon epidermal sutures [Figure 4]. Histopathology revealed residual intradermal melanocytic nevus (congenital type) and scar tissue from prior procedures.

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Figure 1:

(a) Residual intradermal nevus and scar tissue on the left nasal tip following multiple unsuccessful removal attempts over 15 years. (b) Patient 6 weeks post excision and repair via Trilobe Flap. (c) Patient 5 months post scar resurfacing with fractional carbon dioxide laser, dermabrasion, and vascular laser treatment.

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Figure 2:

Ultrasound image revealing residual intradermal nevus and scar tissue; suggestive of incomplete removal. Left arrow shows nasal cartilage. Right arrow shows recurrent intradermal nevus and scar tissue.

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Figure 3:

Preoperative markings and the design of the tri-lobe flap transposition flap.

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Figure 4:

Patient immediately post-operative.

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Histopathology revealed residual intradermal melanocytic nevus (congenital type) and scar tissue from prior procedures. Microscopic examination demonstrated nests of melanocytes arranged in a band-like configuration in the papillary dermis, with melanocytes splayed between collagen bundles and present around blood vessels in the reticular dermis. The specimen also showed fibrillary collagen oriented parallel to the surface with dilated blood vessels oriented perpendicular, consistent with post-procedural scarring. Clear margins were achieved in a single stage.

The patient returned for suture removal after 1 week, and was seen in follow-up at 6 weeks [Figure 1b] for scar resurfacing procedures (dermabrasion and fractional CO₂ UltraPulse DeepFX laser treatment). Post-operative erythema was treated with pulse dye laser, with the final aesthetic result seen at her 5 month follow-up visit. [Figure 1c].

DISCUSSION

Histologically, intradermal nevi are characterized by melanocytic nests confined to the dermis. Incomplete excision leaves remnants of dermal nests, which may result in recurrence. While excision remains the gold standard for removal, other methods include shave removal, laser ablation with continuous CO₂ laser, radiofrequency, electrocautery, cryotherapy, or combinations thereof. The optimal approach depends on factors such as lesion diameter, presence of vellus or terminal hairs, and location. Shave removal has reported recurrence rates of 11.7–33%, whereas laser ablation presents a 7% recurrence rate.^1,2 Surgical excision offers a recurrence rate of <1%, making it the preferred modality for achieving complete and permanent removal.

The pathophysiology of deep scar formation in this case results from repeated trauma and inflammation from multiple failed procedures. Although intradermal nevi are located in the dermis, incomplete removal, followed by repeated ablative treatments, can induce progressive fibrosis that extends beyond the original depth of the nevus. The inflammatory response from multiple procedures creates a cycle of tissue damage and repair, leading to the deep subcutaneous scarring observed on ultrasound.

The demand for nevus removal procedures has increased, possibly due to social media’s influence on modern beauty standards.³ Studies indicate a rise in non-physician practitioners performing mole removals globally, often using destructive techniques rather than excision.³

This case demonstrates how inappropriate mole removal techniques can result in poor cosmetic outcomes, patient dissatisfaction, and distress. Recurrent nevi often appear atypical under dermoscopy, increasing biopsy rates and raising concerns about dysplastic nevi or melanoma. Despite multiple prior treatments, the patient experienced recurrence and was inappropriately treated with electrocauterization, resulting in scarring. Subsequent treatments, including microneedling with radiofrequency (Morpheus8) and non-ablative fractional CO₂ laser (Fraxel), did not result in acceptable cosmetic outcomes, likely due to inappropriate treatment choices given extensive scar and recurrent nevus tissue. Rather, these treatments likely contributed to her hypopigmentation. Since the intradermal nevus was never entirely removed, repeated trauma and inflammation led to hypertrophic scarring over the recurrent nevus.

In this case, continued ablative treatments would have been inappropriate for several reasons: (1) fractional CO₂ laser cannot remove residual nevus tissue as it is a resurfacing technique rather than an excisional modality, (2) the patient had already demonstrated failure of multiple laser approaches, and (3) continued ablative treatments without complete nevus removal would likely perpetuate the cycle of recurrence and progressive scarring.

A trilobe flap is conventionally used for defects on the lower third of the nose, recruiting proximal tissue to reconstruct the nasal tip and ala.⁴ While a bilobed flap is ideal for defects measuring 1.0–1.5 cm, a trilobed flap is better suited for defects between 1.6 and 2.5 cm. Trilobed flaps are well-established, standard reconstructive techniques appropriate for nasal tip defects of this size, regardless of the underlying pathology etiology. Superior tissue recruitment enables the surgeon to utilize well-matched nasal tissue, thereby eliminating the need for larger flaps, such as a paramedian forehead flap. This repair design is advantageous, as simple linear excisions on the nasal tip risk asymmetry or alar rim displacement.

Treatment considerations vary across different skin types, and these factors influenced our management approach. For patients with darker skin tones, surgical excision generally carries a lower risk profile compared to repeated ablative procedures, which have higher risks of post-inflammatory hyperpigmentation. The surgical approach demonstrated in this case would be equally appropriate for patients with skin of color due to the reduced risk of pigmentary complications compared to continued laser treatments.

Once the area had healed sufficiently, the patient underwent two additional procedures to enhance the scar’s appearance and texture. Manual dermabrasion was performed to address surface irregularities, with careful depth control to reduce the risk of additional scarring, hypopigmentation, or contracture. The patient was then treated with DeepFX fractional CO₂ Ultrapulse laser. Fractional ablative technology removes columns of scar tissue, stimulating collagen regeneration in an orientation that resembles healthy tissue.⁵

This case provides several important educational messages for current practice: (1) the critical importance of appropriate initial treatment selection to prevent complex complications, (2) the integration of surgical reconstruction with post-operative scar management for optimal outcomes, (3) decision-making frameworks for when surgical excision should be preferred over continued ablative treatments, and (4) the demonstration that proper technique selection can achieve excellent functional and esthetic results even after multiple failed procedures.

CONCLUSION

With the increasing demand for nevus removals, selecting appropriate treatment methods is crucial to limiting recurrence and adverse outcomes. Furthermore, treatment by an experienced surgeon with expertise across dermatologic fields is essential–especially in addressing complications from prior procedures. This case highlights the importance of precise surgical planning and adjunctive therapies in optimizing functional and esthetic results across all patient populations, while demonstrating that trilobed flaps represent a standard and appropriate reconstructive option for nasal tip defects of appropriate size. The multimodal approach presented here offers a framework for managing complex revision cases and achieving excellent outcomes even after multiple failed procedures.