Surgical management of primary melanoma

The outline of the surgical treatment of a primary cutaneous malignant melanoma may be divided into the problems of biopsy, definitive excision and reconstruction of the defect. An excisional, in contrast to an incisional, biopsy provides the full scope of prognostic parameters and should be used whenever possible. General anesthesia is not necessary, and frozen-section examination is inaccurate. An immediate excision biopsy should therefore be performed under local anesthesia as an outpatient procedure. Whenever possible, a margin of 10 mm should be used, as this would mean an adequate and definitive treatment in melanomas up to 1 mm, and possibly 2 mm, in Breslow thickness. In melanomas more than 1-2 mm in thickness a 3-cm free margin instead of a 5-cm free margin is recommended. Many patients, especially those with trunk lesions with a 3-cm free margin may not need a complicated repair, such as a skin graft or a flap. The excision in depth is recommended to be carried perpendicular to the skin and inclusion of underlying fascia is optional, as no study has proved it to be beneficial. The defect after the excision should whenever possible be closed directly. If this is not possible the defect is covered with either a skin graft or a flap and the latter is recommended from both a cosmetic and a functional point of view. If a skin graft has been used, the secondary defect may be reconstructed with a skin expansion technique.