Reconstruction after wide excision of primary cutaneous melanomas: part II—the extremities

Reconstructive Techniques in Melanoma for the Surgical Oncologist

Wounds resulting from wide local excision of melanoma vary in size and complexity, and require individualized solutions to achieve satisfactory closure. Goals of reconstruction include restoration of form, function, and aesthetics while minimizing donor site morbidity without compromising the effectiveness and safety of oncologic melanoma treatment. Optimal reconstruction relies on an in-depth understanding of the defect, locoregional anatomy and vasculature, available donor tissues, and basic wound healing and surgical principles. This article provides a broad overview of preoperative patient, timing, and wound considerations; various surgical techniques for complex reconstruction throughout the body; and postoperative care and complication management.

The ban of the ipsilateral limb as a skin graft donor site after melanoma excision: A critical review

Split-thickness skin grafts are often applied in the management of primary cutaneous melanoma. It is routine surgical practice to use the contralateral limb because of the alleged risk of donor site metastases that may occur when the ipsilateral limb is used. The rationale and clinical evidence for this routine were assessed in light of current understanding of pathways of metastasis of melanoma. We found the preference for the contralateral limb to go back to Paget's ideas on melanoma spread from 1889, and the clinical observation of five cases of split-thickness skin graft donor site metastases in a series of 226 tumours, published in 1962. We traced ten additional reported cases of melanoma metastases occurring in the skin graft donor site. Contralateral donor sites were involved in seven of these cases. In light of current knowledge, the occurrence and the location of any split skin donor site metastasis are to be considered as mere indicators of an aggressive course of systemic disease. Any location of a split skin donor site, whether ipsilateral or contralateral in relation to the primary tumour, may become the location of metastases but chances that such metastases occur are extremely rare. Because of the lack of evidence in favour of the use of the contralateral limb and because of sound considerations in favour of using the ipsilateral limb, we conclude that there is no objective argument to sustain the dogmatic ban of the ipsilateral limb as a donor site for a split-thickness skin graft in melanoma surgery.

The Modified Keystone Flap for Pressure Ulcers: A Modification of the Keystone Flap With Rotation and Advancement

INTRODUCTION

The reconstruction of extensive soft tissue defects from pressure ulcers is a great challenge. Resurfacing such defects with like tissues and minimizing morbidities are important. Here we present our surgical experience using a novel modified keystone flap for pressure ulcer patients.

METHODS

We retrospectively reviewed the data of 13 consecutive cases reconstructed with the modified keystone flaps between March and December, 2017. The mean dimensions of the reconstructed defect were 7.7 × 6.5 cm, while the mean dimensions of the flap were 12.1 × 8.3 cm.

RESULTS

Time efficient reconstructions with the modified keystone flap were performed without any following major complications. Minor wound dehiscence occurred in only one case, which soon healed with conservative management.

CONCLUSIONS

Considering its simple design, reliable flap survival, minimal donor-site morbidity, optimal flap thickness, and evenly distributed surgical tension, our novel technique of the modified keystone flap is as an excellent surgical option for the reconstruction of pressure ulcers in the gluteal region.

Modified keystone flap for extremity defects after Mohs surgery

BACKGROUND

When possible, surgery is the treatment of choice for cutaneous carcinomas, as it allows to us perform the anatomopathological study and control the surgical margins. Mohs micrographic surgery (MMS) controls 100% of the margins, maintains a larger amount of healthy tissue, and a fewer number of recurrences are seen. Large limb surgical defects after MMS are a challenge. Within the different kind of flaps, the keystone flap, which is a fasciocutaneous island advancement flap, is an option.

METHODS

A descriptive study was carried out on the extremity defects that occurred after MMS, which were reconstructed with the modified keystone type flap, during the years 2013-2014 in our department.

RESULTS

Six patients underwent reconstruction surgery with the modified keystone flap. The tumor types presented by the patients were four squamous cell carcinomas and two basal cell carcinomas. Locations of the repaired defects were three in the leg, two in the thigh, and one in the forearm. The average size of the repaired defects was 3.1 cm. The procedure was well tolerated in all cases. No complications were observed, such as postoperative bleeding, infection, or necrosis, or dehiscence of the suture.

CONCLUSIONS

The modified keystone flap has been very helpful for solving the limb defects of these six patients, although they were not compared with other types of reconstruction.

Nonfacial Reconstructive Techniques

BACKGROUND

Nonfacial reconstruction encompasses several anatomic locations with varied topography, skin quality, and tissue reservoirs. Patients also have varied mobility concerns and wound care needs when managing wounds in these areas.

MATERIALS AND METHODS

This article includes techniques and approaches from the dermatologic surgery, plastic surgery, and podiatric surgery literature in an effort to provide a comprehensive overview of the subject matter.

RESULTS AND CONCLUSION

Functionally and esthetically acceptable reconstructions of nonfacial surgical wounds can be accomplished with a variety of techniques based on the characteristics of the wound and unique needs of the patient.

[Giant abdomino-pubic melanoma. A case report]

Cutaneous melanoma patients are usually young adults. The evolution into a nodular form darkens the prognosis because it increases the risk of metastasis occurrence. The only curative treatment is wide surgical excision when extension check is negative. We report a case of abdomino-pubic melanoma original by its amazing size, its spreading, both superficial and nodular, without metastasis, and its late occurrence to a senior patient. Curative management was performed with a plastic surgery technique: the abdominal plasty. The melanoma was removed with free margins and the patient was free of disease at six month. This report illustrates the interest of plastic surgery techniques in oncology. It also confirms that plastic surgeon forms an integral part of a multidisciplinary team managing patients with cutaneous melanoma.