Arch Hand Microsurg.  2022 Sep;27(3):240-246. 10.12790/ahm.22.0005.

Long-term results of wide local excision with concurrent venous free flap reconstruction in subungual melanoma

• Woo SJ
• Ma IZ
• Kwon ST
• Park SO
• Kim BJ
• Hong KY

• KMID: 2532741
• DOI: http://doi.org/10.12790/ahm.22.0005

Abstract

Purpose
Wide local excision (WLE) has been used as an alternative to amputation for preserving the length of the digit in subungual melanoma (SUM). For reconstruction, a free flap could be a more suitable option than a skin graft or a local flap. We investigated the clinical value of WLE with concurrent venous free flap reconstruction in SUM located on the finger and toe.
Methods
Seventeen patients underwent WLE with a concurrent arterialized venous free flap between January 2011 and December 2015. Venous flaps were harvested from the forearm or foot dorsum and inset using a through- or against-valve type.
Results
The mean tumor area was 1.3±0.9 cm2, and the mean resection margin was 5.6±2.3 mm. In histologic analyses, the mean tumor thickness was 1.2±1.1 mm. The mean duration of the follow-up period was 75.5 months. Three patients had local recurrence and one patient had distant metastasis. Reconstruction of the fingers and toes using a venous flap was effective and could be performed without major complications. Patients were satisfied with the functional and aesthetic results.
Conclusion
WLE provides an acceptable local control rate and offers a safe and conservative alternative for the treatment of SUM of the fingers and toes. Concurrent venous free flaps could be a desirable option for aesthetic and functional reconstruction.

Keyword

Malignant melanoma; Subungual melanoma; Wide local excision; Venous free flap

Figure

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  Fig. 1. Patient (case 7) with subungual melanoma on the left third finger. (A) Preoperative clinical photograph. (B) En-bloc excision of the tumor and nail complex with a 5-mm margin. (C) A venous flap harvested from the volar side of the left forearm was anastomosed with one digital artery and two digital veins. (D) Natural contour of the reconstructed finger without any complications at the 8-month follow-up. Written informed consent was obtained for publication of accompanying images.

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  Fig. 2. Patient (case 8) with subungal melanoma on the right first toe. (A) Preoperative clinical photograph. (B) After inset of a venous flap harvested from the dorsal side of the right foot to allow reversed blood flow with the against-valve type. (C) Clinical photograph of a skin defect that occurred at the center of the flap due to trauma 3 months after surgery. (D) Completely healed flap without further treatment at a 5-year follow-up after debridement and skin grafting for the skin defect. Written informed consent was obtained for publication of accompanying images.

Reference

References

1. Brodland DG. The treatment of nail apparatus melanoma with Mohs micrographic surgery. Dermatol Surg. 2001; 27:269–73.

2. Cochran AM, Buchanan PJ, Bueno RA Jr, Neumeister MW. Subungual melanoma: a review of current treatment. Plast Reconstr Surg. 2014; 134:259–73.

3. Takematsu H, Obata M, Tomita Y, Kato T, Takahashi M, Abe R. Subungual melanoma: a clinicopathologic study of 16 Japanese cases. Cancer. 1985; 55:2725–31.

4. Roh MR, Kim J, Chung KY. Treatment and outcomes of melanoma in acral location in Korean patients. Yonsei Med J. 2010; 51:562–8.

5. Nam KW, Bae YC, Nam SB, Kim JH, Kim HS, Choi YJ. Characteristics and treatment of cutaneous melanoma of the foot. Arch Plast Surg. 2016; 43:59–65.

6. Weismann K, Lorentzen HF. Dermoscopic color perspective. Arch Dermatol. 2006; 142:1250.

7. Østlie K, Magnus P, Skjeldal OH, Garfelt B, Tambs K. Mental health and satisfaction with life among upper limb amputees: a Norwegian population-based survey comparing adult acquired major upper limb amputees with a control group. Disabil Rehabil. 2011; 33:1594–607.

8. Moehrle M, Metzger S, Schippert W, Garbe C, Rassner G, Breuninger H. “Functional” surgery in subungual melanoma. Dermatol Surg. 2003; 29:366–74.

9. Anda-Juárez MC, Martínez-Velasco MA, Fonte-Ávalos V, Toussaint-Caire S, Domínguez-Cherit J. Conservative surgical management of in situ subungual melanoma: long-term follow-up. An Bras Dermatol. 2016; 91:846–8.

10. Clarkson JH, McAllister RM, Cliff SH, Powell B. Subungual melanoma in situ: two independent streaks in one nail bed. Br J Plast Surg. 2002; 55:165–7.

11. High WA, Quirey RA, Guillén DR, Munõz G, Taylor RS. Presentation, histopathologic findings, and clinical outcomes in 7 cases of melanoma in situ of the nail unit. Arch Dermatol. 2004; 140:1102–6.

12. Lazar A, Abimelec P, Dumontier C. Full thickness skin graft for nail unit reconstruction. J Hand Surg Br. 2005; 30:194–8.

13. Imakado S, Sato H, Hamada K. Two cases of subungual melanoma in situ. J Dermatol. 2008; 35:754–8.

14. Duarte AF, Correia O, Barros AM, Azevedo R, Haneke E. Nail matrix melanoma in situ: conservative surgical management. Dermatology. 2010; 220:173–5.

15. Chow WT, Bhat W, Magdub S, Orlando A. In situ subungual melanoma: digit salvaging clearance. J Plast Reconstr Aesthet Surg. 2013; 66:274–6.

16. Nakamura Y, Ohara K, Kishi A, et al. Effects of non-amputative wide local excision on the local control and prognosis of in situ and invasive subungual melanoma. J Dermatol. 2015; 42:861–6.

17. Yun MJ, Park JU, Kwon ST. Surgical options for malignant skin tumors of the hand. Arch Plast Surg. 2013; 40:238–43.

18. Park JU, Kim K, Kwon ST. Venous free flaps for the treatment of skin cancers of the digits. Ann Plast Surg. 2015; 74:536–42.

19. Kim BJ, Kim J, Hu J, Kwak Y, Kwon ST. Functional surgery for subungual melanoma: surgical tips based on histological analysis of 21 cadavers. Dermatol Surg. 2022; 48:7–11.

20. Woo SH, Kim KC, Lee GJ, et al. A retrospective analysis of 154 arterialized venous flaps for hand reconstruction: an 11-year experience. Plast Reconstr Surg. 2007; 119:1823–38.

21. Sureda N, Phan A, Poulalhon N, Balme B, Dalle S, Thomas L. Conservative surgical management of subungual (matrix derived) melanoma: report of seven cases and literature review. Br J Dermatol. 2011; 165:852–8.

22. Hayashi K, Uhara H, Koga H, Okuyama R, Saida T. Surgical treatment of nail apparatus melanoma in situ: the use of artificial dermis in reconstruction. Dermatol Surg. 2012; 38:692–4.

23. Debarbieux S, Hospod V, Depaepe L, Balme B, Poulalhon N, Thomas L. Perioperative confocal microscopy of the nail matrix in the management of in situ or minimally invasive subungual melanomas. Br J Dermatol. 2012; 167:828–36.

24. Haddock NT, Wilson SC, Shapiro RL, Choi M. Wide local en bloc excision of subungual melanoma in situ. Ann Plast Surg. 2014; 73:640–4.

25. Jo G, Cho SI, Choi S, Mun JH. Functional surgery versus amputation for in situ or minimally invasive nail melanoma: a meta-analysis. J Am Acad Dermatol. 2019; 81:917–22.

26. Balch CM, Gershenwald JE, Soong SJ, et al. Final version of 2009 AJCC melanoma staging and classification. J Clin Oncol. 2009; 27:6199–206.

27. Yoo H, Kim H, Kwon ST, et al. Tumor invasion in the hyponychium is associated with distant metastasis and poor prognosis in subungual melanoma: a histologic landscape of 44 cases. J Am Acad Dermatol. 2022; 86:1027–34.

28. Nakayama Y, Soeda S, Kasai Y. Flaps nourished by arterial inflow through the venous system: an experimental investigation. Plast Reconstr Surg. 1981; 67:328–34.

29. Baek SM, Weinberg H, Song Y, Park CG, Biller HF. Experimental studies in the survival of venous island flaps without arterial inflow. Plast Reconstr Surg. 1985; 75:88–95.

30. Tsai TM, Matiko JD, Breidenbach W, Kutz JE. Venous flaps in digital revascularization and replantation. J Reconstr Microsurg. 1987; 3:113–9.

31. Yan H, Fan C, Zhang F, Gao W, Li Z, Zhang X. Reconstruction of large dorsal digital defects with arterialized venous flaps: our experience and comprehensive review of literature. Ann Plast Surg. 2013; 70:666–71.

32. Thatte MR, Thatte RL. Venous flaps. Plast Reconstr Surg. 1993; 91:747–51.

33. Yan H, Zhang F, Akdemir O, et al. Clinical applications of venous flaps in the reconstruction of hands and fingers. Arch Orthop Trauma Surg. 2011; 131:65–74.

34. Yan H, Brooks D, Ladner R, Jackson WD, Gao W, Angel MF. Arterialized venous flaps: a review of the literature. Microsurgery. 2010; 30:472–8.