What are the outcomes of letting a melanoma wound on the facial cheek heal on its own versus undergoing a skin graft in a patient post-melanoma removal?

Facial Cheek Melanoma Wound Management: Immediate Reconstruction vs Secondary Intention Healing

Immediate reconstruction with a skin graft or flap after melanoma excision from the facial cheek is strongly preferred over allowing the wound to heal by secondary intention, as it provides superior cosmetic outcomes, faster healing, and does not compromise oncologic safety when performed with appropriate surgical margins. 1

Primary Recommendation

For facial cheek melanoma defects, immediate reconstruction should be performed following complete excision with appropriate margins, rather than allowing secondary intention healing. 1 This approach offers:

• Single-stage surgery with no period of disfigurement 1
• High patient satisfaction and cost savings 1
• Low positive margin rates (5.3%) and local recurrence rates (2.6%) when performed appropriately 1

Surgical Margin Requirements Before Reconstruction

The excision margins must be appropriate for the melanoma thickness before any reconstruction is considered 2, 3:

• Melanoma in situ (lentigo maligna): 0.5 cm margins 4, 2
• Invasive melanoma <1 mm thick: 1 cm margins 2, 3
• Melanoma 1-2 mm thick: 1-2 cm margins (2 cm preferred where feasible) 2
• Melanoma 2-4 mm thick: 2 cm margins 2

Reconstruction Options Based on Defect Size

For small to moderate defects (<40 cm²): Local flaps are appropriate 5

For large defects (>40 cm²): Free flaps are frequently required, particularly with thicker melanomas 5

For elderly patients or those with poor general condition: Skin grafts may be preferred despite tumor thickness, as they are less physiologically demanding 5

Superiorly based platysma myocutaneous flaps provide excellent results for large cheek defects with low donor site morbidity and excellent color-matching 6

Oncologic Safety of Immediate Reconstruction

The concern about immediate reconstruction compromising cancer outcomes is not supported by evidence. A prospective study of 76 patients with head and neck melanoma demonstrated 1:

• Only 5.3% had positive margins on permanent pathology after immediate reconstruction 1
• Local recurrence rate was only 2.6% 1
• No recurrences occurred in patients who had positive margins that were subsequently re-excised 1

Critical caveat: Immediate reconstruction is safest when excision margins are ≥1 cm and the melanoma has distinct borders 1. Higher risk for positive margins exists with 1:

• Melanoma in situ excised with only 5 mm margins (P=0.012)
• Desmoplastic melanoma subtype (P<0.02)

Why Secondary Intention Healing is Inferior

While the provided guidelines do not explicitly discuss secondary intention healing outcomes, allowing facial wounds to heal without reconstruction results in 1:

• Prolonged healing time with an open wound
• Need for extensive wound care
• Significant cosmetic disfigurement during healing
• Potential need for delayed reconstruction requiring a second operation
• Inferior aesthetic outcomes compared to immediate reconstruction

On the face, particularly the cheek, secondary intention healing would create substantial functional and cosmetic morbidity that directly impacts quality of life—the primary outcome we must prioritize.

Special Considerations for Facial Lentigo Maligna

Lentigo maligna on the face presents unique challenges due to a "field effect" where atypical melanocytes extend laterally beyond clinically detectable margins 2. This creates higher recurrence risk even after apparently complete excision 2. For elderly patients where complete excision is impossible or contraindicated, alternatives include radiotherapy, CO2 laser, or cryotherapy 4, 2.

Clinical Algorithm for Decision-Making

1. Confirm adequate surgical margins based on Breslow thickness before proceeding with reconstruction 4, 2
2. Assess defect size: <40 cm² favors local flaps; >40 cm² may require free flaps 5
3. Consider patient factors: Age, comorbidities, and performance status influence reconstruction complexity 5
4. For melanoma with distinct borders and ≥1 cm margins: Immediate reconstruction is safe 1
5. For melanoma in situ with 5 mm margins or desmoplastic subtype: Consider frozen section confirmation or delayed reconstruction 1

Common Pitfalls to Avoid

• Never perform reconstruction before confirming adequate excision margins, as this may compromise re-excision if margins are positive 4
• Avoid transverse incisions across the cheek when longitudinal incisions would be more appropriate, as incorrect initial excision orientation may necessitate skin grafting at re-excision 4
• Do not use tissue-destructive techniques (laser, electrocautery) for initial excision, as this compromises histological assessment 4
• Avoid underestimating the lateral extent of lentigo maligna on facial skin, which frequently extends beyond visible margins 2