Congenital melanocytic nevi remain a subject of controversy with respect to risk of malignant transformation and recommended management. Recent studies indicate a lower malignant risk (0.7 to 2.9 percent) than had previously been estimated. Surgery has not been proven to reduce malignant risk or improve quality of life, and may result in undesirable aesthetic and functional outcomes. In this article, the authors review key controversial issues in the management of congenital melanocytic nevi and re-evaluate indications for surgical treatment. An updated review of controversial topics in the management of congenital melanocytic nevi is presented, and clinical applications are demonstrated through clinical cases. Updates regarding the risks and outcomes of congenital melanocytic nevi patients open a renewed debate with respect to the indications for surgery as well as the extent of surgery that may be suitable. Treatment should be tailored to achieve optimal aesthetic results whereby complete nevus excision is not the goal. As such, nonsurgical management and incomplete nevus excision should be integrated as legitimate parts of any treatment algorithm.

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