Plastic and Reconstructive Surgery • March 2017

Fig. 3. Pathologic findings for nipples removed for oncologic rea-

sons. DCIS, ductal carcinoma in situ; LCIS, lobular carcinoma in situ.

Melanoma Extirpation with Immediate
Reconstruction: The Oncologic Safety and Cost
Savings of Single-Stage Treatment
Sir:
(n = 1568), 80 percent of the 293 recurrences developed
within the first 3 years, but some recurrences (<8 per-
cent) were detected 5 to 10 years after the initial treat-
ment, and a prospective study found that for patients with

I
n the article entitled “Melanoma Extirpation with
Immediate Reconstruction: The Oncologic Safety
and Cost Savings of Single-Stage Treatment” by Kara-
netz et al.,1 the authors discuss the safety and cost sav-
ings of reconstructing melanoma resections in a single
stage. This method clearly provides potential cost
savings to the system and is more convenient for the
patient. However, melanoma is an increasing source
of morbidity and mortality in the United States, with
76,690 individuals diagnosed with malignant mela-
noma, accounting for 9480 deaths in 2013, and with
the incidence of melanoma rising faster than that for
most other solid malignancies.2 Safety, measured in
morbidity, 5-year disease-free recurrence, and 5-year
overall survival are of the most importance.
The authors discuss their positive margin rate and
actual margins at the time of initial resection. The posi-
tive margin rate in this particular series was nine of 534
patients (1.68 percent). This is low compared with a
larger series, as Dhepnorrarat et al. had a positive mar-
gin rate of 4.73 percent in malignant melanoma resec-
tions in 1459 patients.3 Also unclear from the article
is the cost of a potentially more extensive reconstruc-
tion after reconstruction has been completed at the
initial stage and is subsequently found to have a posi-
tive margin on final pathologic evaluation. In addition,
the potential clinical complications of these positive
margins that have already been covered with a flap are
unclear, as monitoring for locoregional recurrence may
become more difficult. The margins in Table 1 appear
to be below the suggested National Comprehensive
Cancer Network guidelines for T3 and T4 lesions, and
should be at least 2 cm by current guidelines.4
The mean follow-up in this study is 1.2 years, whereas
the majority of the surgical oncology literature includes
follow-up up to 5 years for recurrence, disease-free inter-
vals, and overall survival. The National Comprehensive
Cancer Network guidelines on melanoma review several
studies regarding recurrence. In a retrospective study of
patients who initially presented with stage I melanoma
stage I or II at initial presentation, the risk of recurrence
reached a low level by 4.4 years after initial diagnosis.4
In our practice over the past year, approximately
121 melanoma patients have been treated with imme-
diate reconstruction with either primary closure or
skin grafting. This is similar to the authors’ treatment
except we do not perform adjacent tissue rearrange-
ments because we believe that this is oncologically
unsound, as the entire wound bed is potentially con-
taminated with a positive margin. We have not had to
perform any revisions for aesthetic purposes and have
had two positive margins that were easily excised.
Although we applaud the authors’ study with sin-
gle-stage melanoma resection and reconstruction and
the cost savings associated with it, we feel it is impor-
tant to continue to adhere to oncologic principles and
complete margin evaluation before more extensive
reconstruction such as adjacent tissue rearrangements,
which account for 30 percent of the authors’ practice.
We believe that primary closure and skin grafting con-
tinue to be the standard for primary melanoma extir-
pation and wound closure. Further follow-up should
be required to fully assess the safety of these single-
stage resections with adjacent tissue rearrangements.5
DOI: 10.1097/PRS.0000000000003091
Stephen P. Duquette, M.D.
Department of Surgery
Division of Plastic Surgery
Indiana University School of Medicine
William Wooden, M.D.
Department of Surgery
Division of Plastic Surgery
Indiana University School of Medicine
Division of Plastic Surgery
Roudebush VA Medical Center
John Coleman, M.D.
Department of Surgery
Division of Plastic Surgery
Indiana University School of Medicine

796e
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 139, Number 3 • Letters
Sunil Tholpady, M.D., Ph.D.
Department of Surgery
Division of Plastic Surgery
Indiana University School of Medicine
Division of Plastic Surgery
Roudebush VA Medical Center
Indianapolis, Ind.
Correspondence to Dr. Tholpady
Indiana University School of Medicine
Roudebush VA Medical Center
705 Riley Hospital Drive, RI 2514
Indianapolis, Ind. 46202
stholpad@iupui.edu
DISCLOSURE
The authors have no financial disclosures or conflicts of
interest related to this communication.
REFERENCES
1. Karanetz I, Stanley S, Knobel D, et al. Melanoma extirpa-
tion with immediate reconstruction: The oncologic safety
and cost savings of single-stage treatment. Plast Reconstr Surg.
2016;138:256–261.
2. Khan SA, Bank J, Song DH, Choi EA. The skin and sub-
cutaneous tissue. In: Brunicardi F, Andersen DK, Billiar
TR, et al., eds. Schwartz’s Principles of Surgery. 10th ed. New
York: McGraw-Hill; 2014. Available at: http://accesssurgery.
mhmedical.com.proxy.medlib.uits.iu.edu/content.aspx?boo
kid=980&Sectionid=59610858. Accessed July 17, 2016.
3. Dhepnorrarat RC, Lee MA, Mountain JA. Incompletely
excised skin cancer rates: A prospective study of 31,731
skin cancer excisions by the Western Australian Soci-
ety of Plastic Surgeons. J Plast Reconstr Aesthet Surg.
2009;62:1281–1285.
4. National Comprehensive Cancer Network. Melanoma (Ver-
sion 3.2016). Available at: https://www.nccn.org/profession-
als/physician_gls/pdf/melanoma_blocks.pdf. Accessed July
17, 2016.
5. Behan FC, Rozen WM, Kwee MM, Kapila S, Fairbank S,
Findlay MW. Oncologic clearance with preservation of
reconstructive options: Literature review and the ‘delayed
reconstruction after pathology evaluation (DRAPE)’ tech-
nique. ANZ J Surg. 2012;82:780–785.
Reply: Melanoma Extirpation with Immediate
Reconstruction: The Oncologic Safety and Cost
Savings of Single-Stage Treatment
Sir:
Surgical excision of melanoma with histologically
negative margins remains the standard goal of treatment
for cutaneous malignant melanoma. The reported inci-
dence of positive margins following wide local excision
varies between 5 and 22 percent.1–6 Previous studies have
demonstrated that certain tumor and patient character-
istics can predict positive margins following resection of
cutaneous melanoma, which include advanced age and
locally recurrent, ulcerated, T4 tumors.3,7 The results
of our study8 demonstrate lower positive margins rate,
which can be explained by our patient cohort, which
excluded patients with recurrent or metastatic disease.
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
In addition, at the time of the initial biopsy, the major-
ity of patients had either melanoma in situ (n = 194, 37
percent) or T1 stage melanoma (n = 209, 40 percent).
Although primary closure or skin grafting may
be considered the ideal oncologically safe method
of reconstruction following melanoma extirpation,
reconstruction with adjacent tissue transfer offers a ver-
satile alternative, and can improve functional and aes-
thetic results. A study by Sullivan et al.7 demonstrated
that melanoma reconstruction with local flaps does
not delay detection of local recurrence and may even
decrease the incidence of local failure after wide local
excision of head and neck melanomas. At our institu-
tion, in select cases with positive margins following local
flap reconstruction, we work closely with the surgical
oncologist to determine the original tumor location,
aided by knowledge of the original flap design and
use of preoperative photographs. Flaps are returned
to their original location and reoperative margins are
drawn at the proposed original site of tumor by the sur-
gical oncologist to allow for adequate reexcision.
The absence of the delayed reconstruction group
does affect the accuracy of healthcare cost estimations at
the time of the reexcision and reconstruction. However,
the theoretical cost savings that were generated by our bill-
ing department, after reviewing hospital charges for the
single-stage melanoma extirpation and reconstruction
and comparing them to the theoretical costs for two-stage
reconstruction, demonstrated significant cost savings. We
also acknowledge that our follow-up of 1.2 years is a limita-
tion of the study and may be too short to detect the local
recurrence. In the future, a prospective study with 5-year
follow-up and disease-free recurrence rates will be useful
to determine our long-term recurrence rates.
At the time of definitive excision, we adhere to the
current National Comprehensive Cancer Network guide-
lines, which dictate surgical margins based on tumor thick-
ness: 0.5 to 1 cm for melanoma in situ, 1 cm for tumors
less than or equal to 1  mm in thickness, 1  to 2  cm for
tumors 1.01 to 2 mm thick, and 2 cm for tumors greater
than 2 mm in thickness.9 The mean margins of excision
in Table 1 appear to be below the recommended National
Comprehensive Cancer Network guidelines because in
select patients narrower margins of excision were taken in
the cosmetically and functionally sensitive head and neck
region at the discretion of the surgical oncologist follow-
ing extensive preoperative discussion with the patient and
family regarding possible functional deficits.
DOI: 10.1097/PRS.0000000000003092
Irena Karanetz, M.D.
Neil Tanna, M.D., M.B.A.
Division of Plastic and Reconstructive Surgery
Northwell Health
Hofstra Northwell-School of Medicine
New York, N.Y.
Correspondence to Dr. Tanna
130 E 77th St, 10th Floor
New York, N.Y. 11042
ntanna@gmail.com
797e