Educational information, not a prescription. Decisions require specialist assessment; editorial source checking is not equivalent to clinical validation.
The role of plastic surgery in the pathway
Plastic and reconstructive surgery contributes to melanoma care when excision leaves a tissue defect requiring repair or involves structures important for movement, sensation and appearance. Cancer control remains the primary objective: reconstruction is planned alongside excision, without arbitrarily reducing the necessary removal to obtain a smaller scar.
The pathway may involve a dermatologist, surgeon, pathologist, nuclear-medicine physician and oncologist. Selection depends on site, size, melanoma thickness, margins, possible lymph-node involvement and the person’s condition. The same technique is not suitable for everyone, and one patient’s photograph cannot predict another patient’s result.
Preserving function and limiting changes in appearance are legitimate clinical goals for people of every age and gender. They do not promise complete recovery or an invisible scar. Consultation should explain expected benefits, limitations and the possible need for further procedures.
Sources: ESMO — Cutaneous melanoma: Clinical Practice Guideline (2024/2025); Cancer Research UK — Surgery to remove melanoma skin cancer.
Diagnosis first: excisional biopsy and alternatives
Whenever feasible, a suspicious lesion is removed completely with a narrow clinical margin and full-thickness sampling to allow histological examination. This initial diagnostic procedure differs from the subsequent wide local excision after diagnosis. The specimen must permit melanoma assessment, including Breslow thickness, without destroying necessary information.
For very extensive lesions or sites where complete initial removal would cause substantial harm, a specialist may choose a targeted partial biopsy. Its purpose is to obtain an adequate diagnosis; it should not be described as a procedure that necessarily spreads the tumour. The risk of incomplete sampling must instead be considered and explained.
Laser and other destructive techniques do not replace biopsy of a suspicious lesion. Sampling technique, anaesthesia and specimen handling are professional decisions: this guide does not provide operating instructions for performing the procedure.
Sources: ESMO — Cutaneous melanoma: Clinical Practice Guideline (2024/2025); NICE NG14 — Melanoma: assessment and management.
The initial scar and sentinel-node planning
The first excision should be planned with possible later procedures in mind. Scar orientation, the extent of tissue undermining and tissue transfer can affect reconstruction and lymphatic mapping. Where feasible, a straightforward closure helps preserve subsequent options.
It is not correct, however, to say that any previous excision, flap or graft always and irreversibly makes sentinel lymph node biopsy impossible. Previous surgery requires specific assessment of the technique, site and reliability of mapping. Inform the centre and bring both the operative and pathology reports.
Gentle tissue handling, haemostasis and protection of healthy structures help limit complications and local injury. They should not be turned into a simplistic claim that a particular surgical manoeuvre guarantees absence of metastatic spread. Cancer-treatment planning requires clinical and pathological information, not just the size of the scar.
Sources: ESMO — Cutaneous melanoma: Clinical Practice Guideline (2024/2025); NICE NG14 — Melanoma: assessment and management.
Wide local excision: margins and timing
After histological confirmation, additional tissue may need to be removed around the biopsy site. Margins are defined by melanoma characteristics and guidelines. ESMO provides a reference of 0.5 cm for melanoma in situ, 1 cm for invasive melanomas up to 2 mm thick and 2 cm for thicker tumours. These are clinical margins, not measurements for patients to apply independently.
Acral sites, the face and lentigo maligna may require specialist assessment and margin-control strategies. Preserving function and tissue does not mean knowingly accepting oncologically inadequate excision. The final pathology result and possible need for further excision should be discussed before and after reconstruction.
Surgery is arranged promptly according to the case and the centre’s pathway. This guide does not establish a universal three-month deadline that makes waiting safe: staging, sentinel-node assessment and reconstruction must be coordinated by the team.
Sources: ESMO — Cutaneous melanoma: Clinical Practice Guideline (2024/2025).
Direct closure, grafts and flaps: the differences
Direct closure brings the wound edges together with sutures when this is possible without excessive tension or distortion. A graft transfers skin from a donor area to the defect and must obtain nourishment and blood supply from the recipient bed. A flap transfers tissue with its own blood supply, either maintained or re-established through specialist techniques.
Selection considers defect depth and location, skin elasticity, tissue quality, exposed structures, vascular condition and functional goals. There is no absolute hierarchy in which a graft is always preferable to a flap because it supposedly makes recurrence easier to see. Surveillance must also be planned alongside reconstruction.
The surgeon explains why a solution is suitable and what additional scars it involves. A simpler procedure is useful when it adequately resolves the problem; it should not be chosen at the expense of unstable closure, persistent pain or restricted movement.
Sources: Cancer Research UK — Surgery to remove melanoma skin cancer.
Reconstructive techniques and donor sites
Local flaps, including rhomboid designs described by Limberg or Dufourmentel, use tissue adjacent to the defect. Planning must respect blood supply, tension and surrounding structures. The atlas shows an example of design, transfer and suturing: the photographs document a case, not a sequence applicable without surgical training.
Full-thickness grafts contain the epidermis and entire dermis; split-thickness grafts contain the epidermis and part of the dermis. They differ in characteristics, recipient-bed requirements and donor-area management. The groin can provide skin for small full-thickness grafts, but is not universally the best site: colour, thickness, hair and scar visibility all influence selection.
More complex techniques, including distant or microsurgical flaps, may be considered for selected defects. Their use depends on the reconstructive problem rather than a single rule applicable to every exposed bone or tendon.
Sources: Cancer Research UK — Surgery to remove melanoma skin cancer.
Face, ear, hands, feet and the nail apparatus
Near the eyelids, nose, lips and ear, traction can alter function and proportions. In the hands and feet, mobility, sensation, weight bearing and footwear matter. Reconstruction is therefore planned in relation to the whole anatomical unit rather than only the surface requiring coverage.
For nail-apparatus melanoma, amputation is not an inevitable consequence of every diagnosis. In-situ disease or selected lesions without bone invasion may be assessed for tissue-preserving approaches at experienced centres; disease extent may nevertheless make amputation necessary. The decision requires diagnosis, bone assessment where relevant and the ability to obtain adequate margins.
The J-NAIL protocol investigated conservative surgery in a defined population: a research protocol is not conclusive proof that every nail melanoma can be treated identically. Available evidence, individual selection and strategies still under evaluation must be distinguished.
Sources: ESMO — Cutaneous melanoma: Clinical Practice Guideline (2024/2025); Digit-sparing surgery for nail apparatus melanoma in situ: patient outcomes (2019); JCOG1602/J-NAIL — Protocol for non-amputative digit-preserving surgery (2019).
Sentinel lymph node biopsy: coordinating assessment and reconstruction
Sentinel lymph node biopsy is a staging procedure offered in situations defined by risk and melanoma characteristics. Radiotracer mapping and an intraoperative probe help identify drainage; some protocols also use dye. The procedure has limitations and cannot be described as completely reliable in every case.
When indicated, it is coordinated with wide local excision and reconstruction. Anaesthesia, hospital stay, drainage and antibiotic prophylaxis depend on the procedure, site and individual condition: they are not identical mandatory prescriptions for everyone. Dyes can also cause adverse reactions.
Haematoma, seroma, infection, altered sensation and lymphoedema remain possible even with careful technique. Obesity, comorbidities and previous surgery require individual assessment rather than being presented to readers as an automatic list of prohibitions. The result must be interpreted alongside the rest of the staging information.
Sources: ESMO — Cutaneous melanoma: Clinical Practice Guideline (2024/2025); NICE NG14 — Melanoma: assessment and management; Cancer Research UK — Surgery to remove melanoma skin cancer.
Suspicious lymph nodes and advanced disease
A clinically suspicious lymph node requires targeted investigation, often ultrasound and sampling, rather than being treated as a routine indication for sentinel-node assessment. Confirmation of macroscopic nodal disease leads to a different pathway requiring multidisciplinary discussion.
A photograph showing enlarged nodes should no longer be turned into a rule of “immediate radical clearance for everyone”. Neoadjuvant treatment may be considered in defined resectable stage III melanomas; NADINA and the 2025 AIFA pathway describe a specific setting. They do not mean independently delaying an operation or eliminating surgery.
In recurrent disease or skin metastases, surgery can also contribute to local control or relief of bleeding, pain and ulceration. Its goal, extent and relationship with medical treatments must be explained. A palliative aim describes the purpose of a procedure, not abandonment of care.
Sources: NICE NG14 — Melanoma: assessment and management; NADINA — Neoadjuvant nivolumab and ipilimumab in resectable stage III melanoma (2024); AIFA — Neoadjuvant nivolumab–ipilimumab, Law 648/1996 (17 November 2025).
After surgery: the wound, graft and symptoms to report
Before discharge, request written instructions for dressings, movement, weight bearing, hygiene, appointments and contact details. A graft and its donor site may need different care. Stitch removal and return to activity depend on the reconstruction and should not be copied from another patient’s schedule.
Increasing pain, spreading redness, fever, discharge, persistent bleeding or important changes in tissue colour require contact with the team. Loss of tissue viability can have different causes: a photograph alone does not prove technical error. Emergencies require prompt care.
Smoking, diabetes, circulation, nutrition and current medicines may affect the pathway and should be discussed before surgery. Do not independently stop anticoagulants or other treatment. Recovery includes both tissue healing and return to activities, with rehabilitation or psychological support when needed.
Sources: Cancer Research UK — Surgery to remove melanoma skin cancer; NHS — Scars.
Scars, revision and follow-up
Scars change over time and may remain visible, sensitive, raised or tethered. Careful suturing does not guarantee a minimal scar. Once healing is complete, the team may advise scar-care measures; massage or products should not be applied to an open wound without instructions.
It is incorrect to impose a universal ban on revision before five years or a mandatory ten-year wait. Assessment considers scar maturation, functional limitations, cancer risk, necessary surveillance and the proposed procedure. This does not imply that fat grafting, laser or other interventions are always indicated or free of uncertainty after melanoma.
Before revising a changing area, clinical problems must be assessed, including possible recurrence when suspected. New nodules, ulceration or changes near a scar should be shown to a doctor. Follow-up duration and intensity depend on stage and risk; cosmetic revision does not replace surveillance.
Sources: NHS — Scars; Cambridge University Hospitals — Care of your scar; NICE NG14 — Melanoma: assessment and management.
Research and decisions to discuss with the team
Established reconstructive techniques must be distinguished from new uses, tissue-preserving protocols or perioperative strategies still under investigation. A technique described in a small case series or protocol does not automatically become standard for every melanoma. Combining surgery and medicines also requires evidence for the specific setting.
Ask about the cancer-treatment goal, how margins will be assessed, which reconstructive alternatives exist and what would happen if pathology required another operation. Also clarify donor-site scars, complication risks, effects on daily life and the follow-up plan.
If a clinical trial is proposed, the protocol, uncertainties, possible benefits and available alternatives should be explained; participation does not guarantee personal benefit. The linked atlas documents archive cases: it helps explain clinical problems but does not replace surgical assessment or certify that an outcome can be reproduced.
Sources: National Cancer Institute — Cancer Treatment Trials; JCOG1602/J-NAIL — Protocol for non-amputative digit-preserving surgery (2019); ESMO — Cutaneous melanoma: Clinical Practice Guideline (2024/2025).
Sources and update
- ESMO — Cutaneous melanoma: Clinical Practice Guideline (2024/2025)
- Cancer Research UK — Surgery to remove melanoma skin cancer
- NICE NG14 — Melanoma: assessment and management
- Digit-sparing surgery for nail apparatus melanoma in situ: patient outcomes (2019)
- JCOG1602/J-NAIL — Protocol for non-amputative digit-preserving surgery (2019)
- NADINA — Neoadjuvant nivolumab and ipilimumab in resectable stage III melanoma (2024)
- AIFA — Neoadjuvant nivolumab–ipilimumab, Law 648/1996 (17 November 2025)
- NHS — Scars
- Cambridge University Hospitals — Care of your scar
- National Cancer Institute — Cancer Treatment Trials
Editorial revision and source consultation: 17 October 2026. The original contribution is distinguished from the editorial update; no renewed specialist clinical review is certified.
Historical bibliography of the original section
References retained to document the original contribution. Some original citations are incomplete; they are not used as the sole basis for current guidance.
- Borgognoni L. Raccomandazioni cliniche per il melanoma cutaneo. Istituto Toscano Tumori, 2007.
- Garrido I et al. Mélanome et ganglion sentinelle. Encyclopédie Médico-Chirurgicale, Chirurgie Plastique, 2008.
- Lavie A et al. Mise au point sur la prise en charge chirurgicale du mélanome cutané. Revue de la littérature. Ann Chir Plast Esthet, 2007;52:1 (reference as listed in the original version).
- McCarthy. Plastic Surgery, 1990;1.
- McKie R. Skin Cancer. Martin Dunitz, 1996 (reference as listed in the original version).
- Olsen G. The malignant melanoma of the skin. New theories based on a study of 500 cases. Scand Suppl, 1966;365:1–222.
- Salimbeni G, Castagni P, Gandini D et al. Follow Up of 102 patients submitted to surgery for melanoma from 1978–1988. Melanoma Research, 1993;3:1 (reference as listed in the original version).
- Santoni-Rugiu P. Le Plastiche cutanee. Piccin, 1988.
- Wong JH, Cagle LA, Morton D. Lymphatic drainage of skin to a sentinel lymph node in a feline model. Ann Surg, 1991;214:637.