Chapter 28. Operative Management of Melanoma

Wide Local Excision of Melanoma

• Biopsy-proven cutaneous melanoma.

Inguinal Lymph Node Dissection

• Documented metastatic disease in the inguinal lymph nodes with no evidence of distant metastases.
• Metastases detected in the inguinal nodes by sentinel lymph node (SLN) biopsy or by fine needle aspiration or excisional biopsy in a patient with a clinically evident lymph node metastasis.

Full-Thickness Skin Graft

• Coverage of large defects created by wide local excision of a melanoma that cannot be closed primarily or with a local flap.

Absolute

• Inability to close donor site incision.

Relative

• Concern about incomplete resection (positive margins).
• Poor wound conditions (poor vascularization, exposed bone, open joint surfaces).

Wide Local Excision of Melanoma

• Patient position depends on the location of the melanoma to be excised.
• Patients may need to be supine, prone, or in lateral decubitus position.

Inguinal Lymph Node Dissection

• The patient should be supine with the leg slightly flexed at the knee and externally rotated (frog leg position).
• A Foley catheter is placed.
• The abdominal wall, inguinal region, and proximal thigh are prepped and draped into the surgical field.

Full-Thickness Skin Graft

• Patient position depends on the location of the defect to be covered and the donor site.

Wide Local Excision of Melanoma

• Routine wound care.
• Removal of any external sutures at an interval of 7–14 days postoperatively, depending on wound tension and location (eg, shorter interval for facial sutures).
• Patients should protect the surgical site from excessive sun exposure during the first year to prevent darkening of the scar.

Inguinal Lymph Node Dissection

• Patients are admitted overnight with the Foley catheter left in place and the leg elevated.
• Antibiotics are maintained for 24 hours postoperatively.
• Patients may be discharged the next day.
• If the sartorius was transposed, we prefer to send the patient home with crutches and toe-touch weight bearing only.
• Patients are encouraged to wear compression stockings as soon as possible to minimize lymphedema.
• The drain to bulb suction is continued until output is < 30 mL per 24 hours for 2 consecutive days.
  • The drain should not remain in place longer than 3–4 weeks.
  • It may be better to accept a lymphocele than a wound infection.
• Sutures are removed after 10–14 days.
• Patients are followed closely for infection or other wound complications.

Full-Thickness Skin Graft

• Routine wound care for the donor or SLN biopsy site.
• The bolster is removed approximately 5 days after placement (sooner if there is evidence of bleeding or infection). For a tie-over bolster, after the silk ...