Delayed Reconstruction for the Non-Amputative Treatment of Subungual Melanoma

BACKGROUND: In cases of early stage subungual melanoma (SUM), conservative treatment with non-amputative wide excision of the nail unit and subsequent skin graft is preferred over amputation to preserve the involved digit. OBJECTIVE: We report a series of patients with SUM treated with conservative surgery and suggest an effective supplementary treatment process. METHODS: We retrospectively reviewed 10 patients (2 males, 8 females) who were diagnosed with in situ or minimally invasive SUM on the first biopsy and underwent non-amputative wide excision of the nail unit. All patients underwent secondary intention healing during the histopathological re-evaluation of the entire excised lesion, and additional treatment was administered according to the final report. RESULTS: In two of 10 patients, amputation was performed because of the detection of deep invasion (Breslow thickness: 4.0, 2.3 mm) from the final pathologic results, which differed from the initial biopsy. In six patients who received delayed skin graft, the mean total time required for complete healing after secondary intention healing and the skin graft was 66.83+/-15.09 days. As a result of this delayed skin graft, the final scarring was similar to the original shape of the nail unit, scored between 5 and 10 on a visual analogue scale. Most patients were satisfied with this conservative surgery except one patient, who had volar portion involvement and received an interpolated flap instead of a skin graft. CONCLUSION: Our treatment process can reduce the risk of incomplete resection and improve cosmetic outcomes in patients with SUM.

Non-amputative Surgical Management of Subungal Melanoma in Situ / 대한피부과학회지

Subungual melanoma is a variant of acral lentiginous melanoma and is thought to carry a poor prognosis due to difficulties in early diagnosis. Classical management of subungual melanoma is based on the radical surgery of distal phalanx amputation. Instead, conservative treatment with non-amputative wide excision of the nail unit followed by reconstruction has been insufficiently reported, especially in Korea. A 71-year-old woman presented with dark brownish longitudinal bands on her right thumbnail. Punch biopsies from the nail matrix and nail bed showed proliferation of atypical melanocytes without dermal involvement. We describe a case of subungual melanoma in situ of the right thumb, and a non-amputative surgical management which aims to provide adequate clearance of the lesion with minimal morbidity and satisfactory preservation of function for the patient.