- Practice Guideline:
- The special anatomic considerations for the surgical management of melanomas of the fingers and toes include:
- The limited soft tissue between the skin and underlying structures, particularly in the nail apparatus, and the need to balance oncologic control with preservation of function
- The American Academy of Dermatology recommends:
- That wide excision of cutaneous melanoma on the digits should be performed with histologically negative margins:
- But acknowledges that margins may need to be narrower than standard recommendations to preserve function and accommodate the unique anatomy of the fingers and toes
- For subungual melanoma:
- Partial amputation at the distal interphalangeal joint has traditionally been performed to avoid complications from degloving the distal digit:
- But there is no evidence that this improves prognosis or survival compared to more conservative, digit-sparing approaches, especially for thin (≤ 0.8 mm) or in situ lesions
- Digit-sparing surgery with narrower margins may be considered in select cases to maximize function:
- But this approach warrants further investigation
- The depth of excision:
- Is generally recommended to the level of, but not including, the fascia
- These recommendations are based on expert consensus and the anatomic constraints of the digits, as high-level evidence is lacking for these specific sites
- Partial amputation at the distal interphalangeal joint has traditionally been performed to avoid complications from degloving the distal digit:
- That wide excision of cutaneous melanoma on the digits should be performed with histologically negative margins:
- The special anatomic considerations for the surgical management of melanomas of the fingers and toes include:
- In addition to the anatomic and functional constraints previously discussed:
- Several further considerations are critical for the surgical management of melanomas of the fingers and toes
- The limited subcutaneous tissue and proximity to bone, tendon, and neurovascular structures:
- Often necessitate tailored excision techniques and may preclude standard wide excision margins, especially in the nail apparatus and subungual region
- For subungual melanoma:
- Studies have shown that amputation at the level of the distal interphalangeal joint for fingers and at the proximal phalanx or metatarsophalangeal joint for toes achieves local control:
- But more conservative, digit-sparing resections with histologically negative margins are increasingly favored to preserve function:
- As the level of resection does not significantly impact survival when margins are clear
- But more conservative, digit-sparing resections with histologically negative margins are increasingly favored to preserve function:
- Studies have shown that amputation at the level of the distal interphalangeal joint for fingers and at the proximal phalanx or metatarsophalangeal joint for toes achieves local control:
- Acral lentiginous melanomas:
- Which predominate in these locations, are frequently diagnosed at a greater thickness and are associated with higher rates of nodal and systemic metastasis:
- Underscoring the importance of accurate staging and consideration of sentinel lymph node biopsy for invasive lesions
- Which predominate in these locations, are frequently diagnosed at a greater thickness and are associated with higher rates of nodal and systemic metastasis:
- The unique anatomy also complicates reconstruction:
- Often requiring:
- Skin grafts or local flaps to maintain function and cosmesis
- In anatomically complex sites where standard margins are not feasible:
- Staged excision or slow Mohs micrographic surgery may be considered to maximize tissue conservation while ensuring complete tumor removal:
- With retrospective data supporting comparable local control to conventional excision
- Staged excision or slow Mohs micrographic surgery may be considered to maximize tissue conservation while ensuring complete tumor removal:
- Often requiring:
- Finally, the risk of surgical complications including:
- Positive margins, local recurrence, and need for complex reconstruction:
- Is higher in these specialty sites compared to trunk or proximal extremity melanomas:
- Necessitating multidisciplinary planning and patient counseling regarding both oncologic and functional outcomes
- Is higher in these specialty sites compared to trunk or proximal extremity melanomas:
- Positive margins, local recurrence, and need for complex reconstruction:
- References:
- Guidelines of Care for the Management of Primary Cutaneous Melanoma. Swetter SM, Tsao H, Bichakjian CK, et al. Journal of the American Academy of Dermatology. 2019;80(1):208-250. doi:10.1016/j.jaad.2018.08.055.
- Surgical Management of Subungual Melanoma: Mayo Clinic Experience of 124 Cases. Nguyen JT, Bakri K, Nguyen EC, Johnson CH, Moran SL. Annals of Plastic Surgery. 2013;71(4):346-54. doi:10.1097/SAP.0b013e3182a0df64.
- Malignant Melanoma: Beyond the Basics. Pavri SN, Clune J, Ariyan S, Narayan D. Plastic and Reconstructive Surgery. 2016;138(2):330e-340e. doi:10.1097/PRS.0000000000002367.
- Nail Apparatus Melanoma: Current Management and Future Perspectives. Ito T, Hashimoto H, Kaku-Ito Y, Tanaka Y, Nakahara T. Journal of Clinical Medicine. 2023;12(6):2203. doi:10.3390/jcm12062203.
- Current Controversies in Melanoma Treatment. Temple-Oberle C, Nicholas C, Rojas-Garcia P. Plastic and Reconstructive Surgery. 2023;151(3):495e-505e. doi:10.1097/PRS.0000000000009936.
- Surgical Management of Primary Cutaneous Melanomas of the Hands and Feet. Tseng JF, Tanabe KK, Gadd MA, et al. Annals of Surgery. 1997;225(5):544-50; discussion 550-3. doi:10.1097/00000658-199705000-00011.
- Melanoma of the Hands and Feet (With Reconstruction). Ruffolo AM, Sampath AJ, Kozlow JH, Neumeister MW. Clinics in Plastic Surgery. 2021;48(4):687-698. doi:10.1016/j.cps.2021.05.009.
- Slow Mohs Micrographic Surgery for Acral Melanoma Treatment in Korean Patients. Seo J, Oh Y, Kim SK, Roh MR, Chung KY. Dermatologic Surgery : Official Publication for American Society for Dermatologic Surgery [Et Al.]. 2021;47(2):e42-e46. doi:10.1097/DSS.0000000000002827.
- The Rule of 10s Versus the Rule of 2s: High Complication Rates After Conventional Excision With Postoperative Margin Assessment of Specialty Site Versus Trunk and Proximal Extremity Melanomas. Rzepecki AK, Hwang CD, Etzkorn JR, et al. Journal of the American Academy of Dermatology. 2021;85(2):442-452. doi:10.1016/j.jaad.2018.11.008.
Rodrigo Arrangoiz MS, MD, FACS, FSSO 