Case Report
Reconstruction of a thumb defect with Integra following wide local excision of a subungual melanoma

https://doi.org/10.1016/j.bjps.2009.05.010Get rights and content

Summary

We present the case of a patient with a 1.2 mm Breslow thickness subungual melanoma of the thumb who refused the standard treatment of amputation. He underwent a 1 cm wide local excision of the lesion down to bone and the defect was covered with Integra and later grafted. The evidence for increasingly conservative treatment of subungual melanoma is growing. He remains disease free and is left with a fully functional thumb and a good cosmetic result.

Section snippets

Case report

An anxious 44-year-old right hand dominant general practitioner, of Bangladeshi origin, presented with an 11 year history of a pigmented lesion of his right thumb nail bed which had recently become ulcerated (Figure 1). Excision biopsy confirmed the presence of an ulcerated subungual malignant melanoma with a Breslow thickness of 1.2 mm, Clarke's level IV and mitotic rate of 0. The accepted treatment of subungual melanoma is amputation. The patient refused this on the grounds of poor cosmesis

Discussion

Subungual melanoma is rare, representing 2–3% of all cutaneous melanomas in Caucasians.1 Differential diagnosis includes subungual haematoma, pyogenic granuloma, fungal infection and squamous cell carcinoma. Patients with subungual melanoma often present late. A high proportion (36.8%) of subungual melanomas are amelanotic which may also lead to a delay in diagnosis.2 Amputation is disfiguring and reconstruction may be associated with significant donor site morbidity. Amputation through the

Conflict of interest

None.

Funding

None.

References (5)

There are more references available in the full text version of this article.

Cited by (30)

  • Functional Surgery for Malignant Subungual Tumors: A Case Series and Literature Review

    2018, Actas Dermo-Sifiliograficas
    Citation Excerpt :

    Our literature review (summarized in Tables 2 and 3) clearly suggests that functional surgery with WLE is favored over amputation for noninvasive (in situ) or minimally invasive (< 1 mm) MSUTs.6,16 Its indication for thicker lesions is less clear,5,22 but it has been used for both SUM and SUSCC without other poor prognostic factors and for patients who have refused amputation.38 Local recurrence rates are low in SUSCC (8.7%) and SUM (4.9%).

  • Dermal skin substitutes for upper limb reconstruction: Current status, indications, and contraindications

    2014, Hand Clinics
    Citation Excerpt :

    A 100% graft take and full range of motion were achieved in most patients. Only a few case reports are currently available that discuss the role of dermal substitutes to reconstruct skin defects following tumors resection.31–33 Although the radial forearm flap is regarded as a workhorse flap in reconstructive surgery, the aesthetic and functional morbidity of the donor-site remain a considerable concern.

  • Integra™ permits early durable coverage of improvised explosive device (IED) amputation stumps

    2013, Journal of Plastic, Reconstructive and Aesthetic Surgery
    Citation Excerpt :

    A multicentre randomised controlled trial of 106 patients with major burns later highlighted the benefits of the use of Integra for coverage in major burns.8 The use of dermal substitutes has since expanded to include reconstruction of other full thickness defects including reconstruction following release of scar contracture,9,10 excision of skin tumours11–13 and flap donor sites. However, there is little experience in the use of dermal substitutes in traumatic wounds,14–18 particularly in complex, highly contaminated IED blast injuries.

  • Current surgical management for melanoma

    2024, Journal of Dermatology
View all citing articles on Scopus
View full text