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demonstrating that biopsy specimens represent only a part of the total tumor and often underestimate the true Breslow thickness of the overall lesion&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Most excisional biopsies for suspected melanoma are performed using an elliptical incision with narrow margins and primary closure of the defect&#46; The standard ellipse is designed with a long axis 2&#46;5&#8211;3 times the length of the outer border of the proposed surgical margin &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; This practice ultimately leads to larger wounds that are more complex to reconstruct and have a higher risk of surgical morbidity&#44; as well as leaving a relatively long scar&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Although the current standard practice of wide local excision for melanoma treatment should not be compromised&#44; the situation would be optimized if morbidity and scaring could be reduced while maintaining the same standards applied for wide local excision&#46; To this end&#44; when the diagnosis of a clinically suspected melanoma requires excisional biopsy&#44; we propose a double M-plasty technique &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">To design a double M-plasty&#44; we first draw the ellipse described above&#46; Points &#8220;A&#8221; on the main axis are placed 1<span class="elsevierStyleHsp" style=""></span>mm from the border of the melanoma&#44; and points &#8220;B&#8221; are situated at the midpoint of the section between point &#8220;A&#8221; and the apex of the ellipse&#46; Lines perpendicular to the long axis are then drawn through each point &#8220;B&#8221;&#59; these lines will give 4 points &#8220;C&#8221; at the intersections of the perpendiculars with the outline of the ellipse&#44; allowing 4 line segments &#8220;AC&#8221; to be drawn&#44; thus defining the double M-plasty&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">This technique has the advantage of leaving a scar that shows exactly where the melanoma was located prior to removal &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#44; segment &#8220;AA&#8221;&#41;&#44; which will enable us to measure the subsequent surgical margin with much greater accuracy in the definitive excision and thus minimize the need to excise excessive tissue&#46; For example&#44; for a melanoma with a diameter of 8<span class="elsevierStyleHsp" style=""></span>mm&#44; the length of segment AA would be 1<span class="elsevierStyleHsp" style=""></span>cm instead of 2&#46;5-3&#46;6<span class="elsevierStyleHsp" style=""></span>cm&#46; As the surface area of an ellipse is directly proportional to the radius&#44; the area of skin removed using the double M-plasty technique would be 2&#8211;3 times smaller than with a conventional elliptic excisional biopsy&#44; though the standard surgical margins recommended for a given Breslow thickness would still be satisfied&#46; In addition&#44; the remaining surgical wound of the double M-plasty would be much simpler to close&#44; with a lower morbidity and a better cosmetic outcome as the scar is shorter and less visible &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Not only does this technique leave a clear indication of the site of the tumor for the definitive surgical excision&#44; but it also has the advantages of tissue conservation and scar length shortening&#44; which have been widely discussed in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5&#44;6</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In summary&#44; the double M-plasty is applied as a modification of the traditional elliptical excision&#46; This modification is widely used for the resection of benign and malignant lesions&#44; especially those in areas adjacent to critical structures such as the eyebrow&#44; the vermillion border of the lip&#44; or the chin skin crease&#46; The double M-plasty is generally used to make direct closure of a wound possible with lower tension and a shorter scar length&#44; in addition to avoiding crossing multiple cosmetic units within the repair&#46; When performing an excisional biopsy for a suspected melanoma&#44; the double M-plasty has the additional advantage of identifying the exact site of the primary lesion&#44; which will give us greater control over the width of the surgical margins&#46; In our experience&#44; this has resulted in greater sparing of healthy tissue&#44; less disruption of lymph drainage&#44; and a lower overall morbidity&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">Authors declare no conflict of interest&#46;</p></span></span>"
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Case and Research Letter
Double M-plasty for Excisional Biopsy of Suspected Melanoma
Biopsia escisional por M-plastia doble para lesiones sospechosas de Melanoma
C. Agorioa,
Autor para correspondencia
agorionor@gmail.com.uy

Corresponding author.
, J. Maglianoa, J.D. Brewerb, C.I. Bazzanoa
a Dermatologic Surgery Unit, Department of Dermatology, Hospital de Clínicas Dr. Manuel Quintela, Universidad de la República, Montevideo, Uruguay
b Department of Dermatology, Mayo Clinic, Rochester, MN, USA
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        "titulo" => "Biopsia escisional por M-plastia doble para lesiones sospechosas de Melanoma"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Double M-plasty design for a suspected melanoma lesion&#46; &#40;B&#41; Scar of the primary site of a malignant melanoma is clearly identifiable after a double M-plasty&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">There are 2 stages to the diagnosis and surgical treatment of melanoma&#46; First a biopsy is performed to obtain histological confirmation of the diagnosis&#59; this may be a punch or shave biopsy or an excisional biopsy with a narrow margin of 1&#8211;2<span class="elsevierStyleHsp" style=""></span>mm&#46; The definitive surgical approach will depend on the histological findings&#46; Surgical excision of a previously biopsied and confirmed melanoma is performed via re-excision with surgical margins of 0&#46;5&#8211;2<span class="elsevierStyleHsp" style=""></span>cm&#44; depending on the Breslow thickness&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> For many authors&#44; however&#44; partial biopsies are not recommended in melanoma patients because of the higher risk of misdiagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The high incidence of invasive disease in lesions initially diagnosed as melanoma in situ has been widely reported&#44; demonstrating that biopsy specimens represent only a part of the total tumor and often underestimate the true Breslow thickness of the overall lesion&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Most excisional biopsies for suspected melanoma are performed using an elliptical incision with narrow margins and primary closure of the defect&#46; The standard ellipse is designed with a long axis 2&#46;5&#8211;3 times the length of the outer border of the proposed surgical margin &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; This practice ultimately leads to larger wounds that are more complex to reconstruct and have a higher risk of surgical morbidity&#44; as well as leaving a relatively long scar&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Although the current standard practice of wide local excision for melanoma treatment should not be compromised&#44; the situation would be optimized if morbidity and scaring could be reduced while maintaining the same standards applied for wide local excision&#46; To this end&#44; when the diagnosis of a clinically suspected melanoma requires excisional biopsy&#44; we propose a double M-plasty technique &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">To design a double M-plasty&#44; we first draw the ellipse described above&#46; Points &#8220;A&#8221; on the main axis are placed 1<span class="elsevierStyleHsp" style=""></span>mm from the border of the melanoma&#44; and points &#8220;B&#8221; are situated at the midpoint of the section between point &#8220;A&#8221; and the apex of the ellipse&#46; Lines perpendicular to the long axis are then drawn through each point &#8220;B&#8221;&#59; these lines will give 4 points &#8220;C&#8221; at the intersections of the perpendiculars with the outline of the ellipse&#44; allowing 4 line segments &#8220;AC&#8221; to be drawn&#44; thus defining the double M-plasty&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">This technique has the advantage of leaving a scar that shows exactly where the melanoma was located prior to removal &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#44; segment &#8220;AA&#8221;&#41;&#44; which will enable us to measure the subsequent surgical margin with much greater accuracy in the definitive excision and thus minimize the need to excise excessive tissue&#46; For example&#44; for a melanoma with a diameter of 8<span class="elsevierStyleHsp" style=""></span>mm&#44; the length of segment AA would be 1<span class="elsevierStyleHsp" style=""></span>cm instead of 2&#46;5-3&#46;6<span class="elsevierStyleHsp" style=""></span>cm&#46; As the surface area of an ellipse is directly proportional to the radius&#44; the area of skin removed using the double M-plasty technique would be 2&#8211;3 times smaller than with a conventional elliptic excisional biopsy&#44; though the standard surgical margins recommended for a given Breslow thickness would still be satisfied&#46; In addition&#44; the remaining surgical wound of the double M-plasty would be much simpler to close&#44; with a lower morbidity and a better cosmetic outcome as the scar is shorter and less visible &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Not only does this technique leave a clear indication of the site of the tumor for the definitive surgical excision&#44; but it also has the advantages of tissue conservation and scar length shortening&#44; which have been widely discussed in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5&#44;6</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In summary&#44; the double M-plasty is applied as a modification of the traditional elliptical excision&#46; This modification is widely used for the resection of benign and malignant lesions&#44; especially those in areas adjacent to critical structures such as the eyebrow&#44; the vermillion border of the lip&#44; or the chin skin crease&#46; The double M-plasty is generally used to make direct closure of a wound possible with lower tension and a shorter scar length&#44; in addition to avoiding crossing multiple cosmetic units within the repair&#46; When performing an excisional biopsy for a suspected melanoma&#44; the double M-plasty has the additional advantage of identifying the exact site of the primary lesion&#44; which will give us greater control over the width of the surgical margins&#46; In our experience&#44; this has resulted in greater sparing of healthy tissue&#44; less disruption of lymph drainage&#44; and a lower overall morbidity&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">Authors declare no conflict of interest&#46;</p></span></span>"
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