Surgical Procedures

Skin Excision For Melanoma

David R. Farley, M.D.
Dr. David R Farley breaks down the details of skin excision for melanoma, including procedure, indications, and risks.
8/18/2021
General Surgery
GIBLIB


Student Author

Mario Gaddini, Nathan Leavitt, Matthew Zeller


BACKGROUND INFORMATION:


Melanoma is the malignant transformation of the melanocytes within the skin. Melanomas occur most commonly on sun-exposed areas, including the face, scalp, nail beds, back, and extremity skin.  


Surgical management is critical for the diagnosis, staging, and treatment of melanoma. The goals of surgery include:

  • Histologic confirmation of the diagnosis,
  • Obtaining complete and accurate microstaging of the primary tumor, and
  • Excision of the primary site with an appropriate margin of normal tissue, minimizing the risk of local recurrence without compromising additional staging maneuvers.

Based on the staging, the procedure may consist of only wide local excision or extend to involve lymph node biopsy or dissection.


INDICATIONS: If a melanoma is suspected, a full-thickness biopsy of the lesion is required for diagnosis and surgical planning. Based on the biopsy result, lesions are clinically staged according to their thickness and the presence of regional lymph node involvement or lymphatic metastases on a clinical exam or imaging. The thickness of the melanoma is a key factor in determining the clinical stage of the lesion and the recommended margin of normal tissue to resect.

Tumor Category (Breslow Thickness)

  • Resection Margin
  • Melanoma in situ
  • 0.5 to 1 cm margin
  • T1 (≤1.0 mm)
  • 1 cm margin
  • T2 (>1 to 2 mm)
  • 1 to 2 cm margin
  • T3/T4 (>2 to 4/>4 mm)
  • 2 cm margin


PROCEDURE DESCRIPTION: The surgical approach varies based on the location of the lesion. Most excisions are performed using an elliptical incision which facilitates straight-line closure along natural tension lines. The required margin is measured in the short axis of the ellipse and is typically excised down to the muscle fascia. The specimen is excised and removed and oriented for pathological evaluation.

Sentinel lymph node biopsies provide diagnostic information that is important for further treatment decisions. They are typically performed for patients with melanomas at intermediate or high risk for lymph node metastasis, including melanomas greater than 0.8 mm thick (T1b-4) and melanomas less than 0.8 mm thick but with ulceration (T1b)2. For positive sentinel node biopsies, complete lymph node dissection may be required.



KEY ANATOMY:

Layers of the skin down to the fascia of the underlying muscle belly, as well as:

  • Epidermis
  • Dermis
  • Subcutaneous Fat
  • Lymphatic Drainage, Dependant on Melanoma Location
  • Groin Lymphatics: Superficial Inguinal Lymph Nodes
  • Drain Vulva, Scrotum, Anus Below Pectinate Line, and Skin of the Groin Below the Umbilicus.


RISKS:

  • Local Bleeding
  • Infection
  • Disease Recurrence
  • Lymphatic Leak after Sentinel Lymph Node Biopsy or Dissection
  • Seroma


KEY LITERATURE:

  • Guidelines of care for the management of primary cutaneous melanoma3

https://pubmed.ncbi.nlm.nih.gov/30392755/


  • AJCC Melanoma Staging Guidelines, 8th Edition2

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5978683/

To watch the surgery live, click here: https://watch.giblib.com/video/7716


Watch Video

EARN CME

Watch, learn, and earn unlimited AMA PRA Category 1 Credit(s)™. Our continuing medical education process is simple, fast and efficient. Get access to thousands of accredited medical lectures, surgical videos, and courses. Clinician-learners complete an assessment test and can download CME certificates instantly.

ABOUT GIBLIB

GIBLIB is the premier streaming service with a vast catalog of unrivaled continuing medical education content covering surgical videos, medical lectures, courses, and transcripts. Learn from the world’s best doctors, from the top leading institutions, including Mayo Clinic, UCSF, Cedars-Sinai, Keck Medicine of USC, and many more.

View recent posts

Trending Topics
Weight Gain in Midlife Women: What to Do About the Middle Age Spread?
One of the most common questions women ask their healthcare providers is “why am I gaining weight despite doing everything the same/right?” Kapoor, MBBS explains causes and treatment options.
Medical Lectures
The Importance of Compassion: Compassion in the Hospital Setting
In a John Hopkins study, 56% of physicians surveyed said they don't have time for compassion – but that is what your patients need the most. Learn how compassion betters hospital care
COVID-19 Updates
Breaking down COVID-19 vaccine booster approvals
In this Mayo Clinic Q&A podcast, Dr. Poland talks about the approval process for COVID-19 vaccine boosters, including for the Moderna and J&J COVID-19 vaccines, as well as the possibility of emergency use approval for children, down to age 5, before the end of October.
Start 4-day FREE trial and get unlimited access to surgical videos, medical lectures, and courses.
Get Started