Case and Research Letter
Double M-plasty for Excisional Biopsy of Suspected Melanoma
Biopsia escisional por M-plastia doble para lesiones sospechosas de Melanoma
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Agorio, J. Magliano, J.D. Brewer, C.I. Bazzano" "autores" => array:4 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Agorio" "email" => array:1 [ 0 => "agorionor@gmail.com.uy" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "Magliano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "J.D." "apellidos" => "Brewer" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "C.I." "apellidos" => "Bazzano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Dermatologic Surgery Unit, Department of Dermatology, Hospital de Clínicas Dr. Manuel Quintela, Universidad de la República, Montevideo, Uruguay" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Dermatology, Mayo Clinic, Rochester, MN, USA" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Biopsia escisional por M-plastia doble para lesiones sospechosas de Melanoma" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 867 "Ancho" => 2442 "Tamanyo" => 316505 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Double M-plasty design for a suspected melanoma lesion. (B) Scar of the primary site of a malignant melanoma is clearly identifiable after a double M-plasty.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">There are 2 stages to the diagnosis and surgical treatment of melanoma. First a biopsy is performed to obtain histological confirmation of the diagnosis; this may be a punch or shave biopsy or an excisional biopsy with a narrow margin of 1–2<span class="elsevierStyleHsp" style=""></span>mm. The definitive surgical approach will depend on the histological findings. Surgical excision of a previously biopsied and confirmed melanoma is performed via re-excision with surgical margins of 0.5–2<span class="elsevierStyleHsp" style=""></span>cm, depending on the Breslow thickness.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> For many authors, however, partial biopsies are not recommended in melanoma patients because of the higher risk of misdiagnosis.<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, demonstrating that biopsy specimens represent only a part of the total tumor and often underestimate the true Breslow thickness of the overall lesion.<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. The standard ellipse is designed with a long axis 2.5–3 times the length of the outer border of the proposed surgical margin (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). This practice ultimately leads to larger wounds that are more complex to reconstruct and have a higher risk of surgical morbidity, as well as leaving a relatively long scar.</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, the situation would be optimized if morbidity and scaring could be reduced while maintaining the same standards applied for wide local excision. To this end, when the diagnosis of a clinically suspected melanoma requires excisional biopsy, we propose a double M-plasty technique (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">To design a double M-plasty, we first draw the ellipse described above. Points “A” on the main axis are placed 1<span class="elsevierStyleHsp" style=""></span>mm from the border of the melanoma, and points “B” are situated at the midpoint of the section between point “A” and the apex of the ellipse. Lines perpendicular to the long axis are then drawn through each point “B”; these lines will give 4 points “C” at the intersections of the perpendiculars with the outline of the ellipse, allowing 4 line segments “AC” to be drawn, thus defining the double M-plasty.</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 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C, segment “AA”), 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. For example, for a melanoma with a diameter of 8<span class="elsevierStyleHsp" style=""></span>mm, the length of segment AA would be 1<span class="elsevierStyleHsp" style=""></span>cm instead of 2.5-3.6<span class="elsevierStyleHsp" style=""></span>cm. As the surface area of an ellipse is directly proportional to the radius, the area of skin removed using the double M-plasty technique would be 2–3 times smaller than with a conventional elliptic excisional biopsy, though the standard surgical margins recommended for a given Breslow thickness would still be satisfied. In addition, the remaining surgical wound of the double M-plasty would be much simpler to close, with a lower morbidity and a better cosmetic outcome as the scar is shorter and less visible (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Not only does this technique leave a clear indication of the site of the tumor for the definitive surgical excision, but it also has the advantages of tissue conservation and scar length shortening, which have been widely discussed in the literature.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5,6</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In summary, the double M-plasty is applied as a modification of the traditional elliptical excision. This modification is widely used for the resection of benign and malignant lesions, especially those in areas adjacent to critical structures such as the eyebrow, the vermillion border of the lip, or the chin skin crease. The double M-plasty is generally used to make direct closure of a wound possible with lower tension and a shorter scar length, in addition to avoiding crossing multiple cosmetic units within the repair. When performing an excisional biopsy for a suspected melanoma, the double M-plasty has the additional advantage of identifying the exact site of the primary lesion, which will give us greater control over the width of the surgical margins. In our experience, this has resulted in greater sparing of healthy tissue, less disruption of lymph drainage, and a lower overall morbidity.</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.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1333 "Ancho" => 1201 "Tamanyo" => 174465 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) The design of an elliptical excision. The blue line indicates the length of the surgical scar after closure. (B) Design of the double M-plasty. (C) Excision of the double M-plasty (the red arrows indicate closure of the central area, green arrows indicate the closure of the ends of the scar, and the blue line A-A indicates the exact site where the suspicious lesion was located).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 867 "Ancho" => 2442 "Tamanyo" => 316505 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Double M-plasty design for a suspected melanoma lesion. (B) Scar of the primary site of a malignant melanoma is clearly identifiable after a double M-plasty.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis and treatment of melanoma. European consensus-based interdisciplinary guideline – update 2012" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Garbe" 1 => "K. Peris" 2 => "A. Hauschild" 3 => "P. Saiag" 4 => "M. Middleton" 5 => "A. 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Procedural dermatology" "paginaInicial" => "259" "paginaFinal" => "266" "serieFecha" => "2005" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0055" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The nested M-plasty for scar length shortening" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.S. Krishnan" 1 => "H.B. Donnelly" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1524-4725.2008.34265.x" "Revista" => array:6 [ "tituloSerie" => "Dermatol Surg" "fecha" => "2008" "volumen" => "34" "paginaInicial" => "1236" "paginaFinal" => "1238" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18554292" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0060" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "M-plasty techniques" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.C. Webster" 1 => "T.M. Davidson" 2 => "R.C. Smith" 3 => "G.G. Kitchens" 4 => "A.A. Clairmont" 5 => "T.H. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 10 | 9 | 19 |
| 2024 Octubre | 87 | 63 | 150 |
| 2024 Septiembre | 101 | 46 | 147 |
| 2024 Agosto | 123 | 83 | 206 |
| 2024 Julio | 106 | 76 | 182 |
| 2024 Junio | 85 | 51 | 136 |
| 2024 Mayo | 102 | 54 | 156 |
| 2024 Abril | 88 | 42 | 130 |
| 2024 Marzo | 102 | 43 | 145 |
| 2024 Febrero | 90 | 37 | 127 |
| 2024 Enero | 93 | 36 | 129 |
| 2023 Diciembre | 95 | 19 | 114 |
| 2023 Noviembre | 112 | 33 | 145 |
| 2023 Octubre | 97 | 28 | 125 |
| 2023 Septiembre | 88 | 26 | 114 |
| 2023 Agosto | 98 | 17 | 115 |
| 2023 Julio | 99 | 28 | 127 |
| 2023 Junio | 89 | 37 | 126 |
| 2023 Mayo | 109 | 21 | 130 |
| 2023 Abril | 114 | 24 | 138 |
| 2023 Marzo | 81 | 36 | 117 |
| 2023 Febrero | 133 | 27 | 160 |
| 2023 Enero | 64 | 30 | 94 |
| 2022 Diciembre | 85 | 37 | 122 |
| 2022 Noviembre | 32 | 18 | 50 |
| 2022 Octubre | 41 | 23 | 64 |
| 2022 Septiembre | 52 | 46 | 98 |
| 2022 Agosto | 49 | 34 | 83 |
| 2022 Julio | 52 | 30 | 82 |
| 2022 Junio | 38 | 34 | 72 |
| 2022 Mayo | 111 | 35 | 146 |
| 2022 Abril | 105 | 27 | 132 |
| 2022 Marzo | 92 | 36 | 128 |
| 2022 Febrero | 73 | 28 | 101 |
| 2022 Enero | 108 | 40 | 148 |
| 2021 Diciembre | 77 | 32 | 109 |
| 2021 Noviembre | 91 | 38 | 129 |
| 2021 Octubre | 110 | 59 | 169 |
| 2021 Septiembre | 101 | 46 | 147 |
| 2021 Agosto | 70 | 33 | 103 |
| 2021 Julio | 75 | 33 | 108 |
| 2021 Junio | 96 | 44 | 140 |
| 2021 Mayo | 75 | 40 | 115 |
| 2021 Abril | 292 | 82 | 374 |
| 2021 Marzo | 138 | 22 | 160 |
| 2021 Febrero | 86 | 31 | 117 |
| 2021 Enero | 70 | 17 | 87 |
| 2020 Diciembre | 62 | 26 | 88 |
| 2020 Noviembre | 55 | 34 | 89 |
| 2020 Octubre | 63 | 25 | 88 |
| 2020 Septiembre | 91 | 18 | 109 |
| 2020 Agosto | 49 | 25 | 74 |
| 2020 Julio | 47 | 14 | 61 |
| 2020 Junio | 43 | 35 | 78 |
| 2020 Mayo | 23 | 12 | 35 |
| 2020 Abril | 37 | 21 | 58 |
| 2020 Marzo | 21 | 12 | 33 |
| 2020 Febrero | 3 | 1 | 4 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 9 | 2 | 11 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Octubre | 1 | 0 | 1 |
| 2019 Septiembre | 6 | 0 | 6 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 4 | 0 | 4 |
| 2019 Mayo | 6 | 2 | 8 |
| 2019 Abril | 2 | 1 | 3 |
| 2019 Marzo | 4 | 4 | 8 |
| 2019 Enero | 5 | 0 | 5 |
| 2018 Diciembre | 3 | 0 | 3 |
| 2018 Noviembre | 4 | 0 | 4 |
| 2018 Octubre | 23 | 0 | 23 |
| 2018 Septiembre | 40 | 0 | 40 |
| 2018 Abril | 0 | 2 | 2 |
| 2018 Marzo | 20 | 3 | 23 |
| 2018 Febrero | 81 | 3 | 84 |
| 2018 Enero | 93 | 7 | 100 |
| 2017 Diciembre | 41 | 5 | 46 |
| 2017 Noviembre | 44 | 9 | 53 |
| 2017 Octubre | 50 | 5 | 55 |
| 2017 Septiembre | 39 | 9 | 48 |
| 2017 Agosto | 57 | 16 | 73 |
| 2017 Julio | 26 | 8 | 34 |
| 2017 Junio | 48 | 15 | 63 |
| 2017 Mayo | 44 | 11 | 55 |
| 2017 Abril | 26 | 6 | 32 |
| 2017 Marzo | 18 | 12 | 30 |
| 2017 Febrero | 57 | 7 | 64 |
| 2017 Enero | 27 | 12 | 39 |
| 2016 Diciembre | 27 | 11 | 38 |
| 2016 Noviembre | 15 | 15 | 30 |
| 2016 Octubre | 15 | 21 | 36 |
| 2016 Septiembre | 0 | 9 | 9 |
| 2016 Agosto | 0 | 5 | 5 |
| 2016 Julio | 0 | 1 | 1 |
| 2016 Junio | 0 | 1 | 1 |
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