Managing malignant melanoma.

Sir: We read with great interest the article by Dr. Dzwierzynski entitled “Managing Malignant Melanoma.”1 In his article, the author provides a comprehensive review of the diagnosis and management of this dreadful skin cancer. We congratulate Dr. Dzwierzynski for the meticulous work, and we would like to complement his review by further discussing reconstructive options after melanoma primary excision and/or margin widening. As outlined by the author, wide tumor excision, including the subcutaneous tissue down to the fascia, stands as the mainstay of therapy for patients with primary or recurrent melanoma. The excision margins recommended to achieve oncological safety often lead to large wounds with both functional and aesthetic impairment. Consequently, plastic surgeons must often perform complex reconstruction to achieve adequate morphofunctional restoration. Adequate preoperative planning is crucial: it is of paramount importance that the surgical technique performed neither affects the oncological prognosis nor hampers the oncological follow-up. Nevertheless, the ideal type of reconstruction in such cases, whether it be a graft or flap, has not yet been pinpointed.2 For many years, flaps have been considered less safe because of the possibility of camouflaging early melanoma recurrence in the excision bed, although this occurrence remains “lore.”3 However, local flaps may alter lymphatic drainage patterns of the wound site, with potential modification of future lymphatic mapping procedures.4 Therefore, many authors prefer to use graft in order to preserve the lymphatic drainage, and use flaps only when a lymphadenectomy has to be performed.5 In the authors’ opinion, both reconstructive options are viable, and to elucidate this concept, we present five situations that could rise after melanoma excision and reconstruction (Fig. 1).Fig. 1: Five hypothetical cases of advanced melanoma.The first case is that of local recurrence of melanoma. In this situation, using a graft or a flap does not change the surgical procedure, which is that of surgical excision with the recommended margins. A patient with satellitosis or in-transit metastasis will have to be treated with excision of the lesion, irrespective of its appearance in a graft or flap reconstruction. The latter is the case of a patient with nodal metastases. Again, a previous flap mobilization or graft placement does not modify the elective treatment, which is a lymph node biopsy with subsequent lymph node dissection. In case of distal metastasis, the treatment is not related to the type of reconstruction and changes case by case. From our point of view, graft and flap should be considered equivalent and safe alternatives in reconstruction after wide excision of melanomas. We would appreciate Dr. Dzwierzynski’s opinion on this topic, in order to further highlight which treatment would be more appropriate. In addition, creation of a multicenter study to compare overall survival after graft or flap reconstruction following melanoma excision would be very useful. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Pierluigi Gigliofiorito, M.D. Francesco Segreto, M.D. Luca Piombino, M.D. Alfonso Luca Pendolino, M.D. Paolo Persichetti, M.D., Ph.D. Plastic and Reconstructive Surgery Unit, Università Campus Bio-Medico di Roma, Rome, Italy