In short. How melanoma is staged by depth, why wide excision margins are non-negotiable, the role of sentinel lymph node biopsy, and how defects are reconstructed safely.
Key points
- Most melanoma defects close directly or with a local flap; grafts suit broad shallow defects on the scalp, trunk, or limbs.
- Where margins are uncertain, reconstruction is deliberately delayed until pathology confirms clearance — closing a wound beautifully over residual tumour serves nobody.
- Sentinel node biopsy is a staging tool, not a treatment: a positive result changes surveillance and opens the door to modern systemic therapy through oncology colleagues.
Melanoma is the least common of the major skin cancers but the one that kills. Surgery is its primary cure, and the rules are strict: the tumour and a measured margin of surrounding skin must be removed, and the depth of the tumour — the Breslow thickness on the pathology report — dictates how wide that margin must be and whether the draining lymph nodes should be sampled. This is not an area for improvisation.
The problem being solved
A changing mole — asymmetric, irregular-bordered, multi-coloured, enlarging, or newly bleeding — is first biopsied or narrowly excised for diagnosis. Once melanoma is confirmed, the definitive operation is a wide local excision: removing a further margin of skin and fat around the scar, with recommended widths scaled to tumour thickness. Deeper tumours also justify sentinel lymph node biopsy, a staging procedure that finds the first node the tumour would drain to.
Who it suits — and what guides the plan
Every confirmed melanoma patient is a surgical candidate until staging says otherwise. The plan depends on thickness, ulceration, site, and the patient’s general health. Facial melanomas require particular judgement because full margins on the eyelid or nose must be balanced against function; specialized margin-control techniques exist for lentigo maligna, the slowly spreading melanoma of sun-damaged facial skin.
The options compared
Margin first, reconstruction second
Most melanoma defects close directly or with a local flap; grafts suit broad shallow defects on the scalp, trunk, or limbs. Where margins are uncertain, reconstruction is deliberately delayed until pathology confirms clearance — closing a wound beautifully over residual tumour serves nobody. Sentinel node biopsy is a staging tool, not a treatment: a positive result changes surveillance and opens the door to modern systemic therapy through oncology colleagues. The reconstructive surgeon’s loyalty is to the margin first and the closure immediately after.
What surgery can and cannot achieve
Wide excision with clear margins cures most thin melanomas outright. What surgery cannot do is guarantee the future: melanoma can recur locally or distantly years later, which is why structured follow-up with skin and node examination is part of the treatment, and why any new lump or changing mole afterwards matters. Scars are permanent and often longer than patients expect, because margins are measured, not negotiated.
Recovery and surveillance
Most wide excisions are day or short-stay procedures; node biopsy adds a small separate scar and a few days of restricted activity. Follow-up runs for years, with the schedule scaled to stage, and includes whole-body skin checks because one melanoma raises the risk of another.
Risks and honest counsel
Risks include seroma (fluid collection), infection, wound separation, numbness, and lymphoedema after node surgery. The larger risk to life, though, is undertreatment: refusing recommended margins or node staging to avoid a scar is a trade that should be made knowingly, if at all.
Arrange a review urgently if
- A mole is changing in size, shape, or colour, has an irregular edge, or bleeds or crusts without injury.
- You have had melanoma and notice a new lump under the skin, a nodule near the scar, or a swollen node.
- A biopsy report mentions melanoma and you have not yet been offered a definitive excision plan — staging and margins are time-sensitive.
Frequently asked questions
Why does melanoma excision need such wide margins?
Margin width is scaled to the Breslow thickness reported on the biopsy, because melanoma sends roots beyond what is visible. Removing a measured margin of surrounding skin and fat is what makes the operation curative for thin tumours, and the width is not negotiable.
What is a sentinel lymph node biopsy for?
It is a staging procedure, not a treatment. The first node that the tumour would drain to is identified and sampled, and the result tells whether melanoma has spread to the lymph nodes, which changes surveillance and opens the door to systemic therapy.
Why is closure sometimes delayed after melanoma removal?
Where the margins are uncertain, reconstruction waits until pathology confirms the tumour is fully cleared. Closing a wound beautifully over residual melanoma would serve nobody, so the reconstructive surgeon accepts a staged repair in exchange for certainty about clearance.
Risks & Limitations
- Reconstruction is usually staged — more than one operation is normal, and the plan may change as healing progresses.
- Donor-site scarring and discomfort, including after rib cartilage harvest.
- Partial or complete failure of a flap or graft, which may require further surgery.
- Scars are permanent. They mature and fade but never disappear.
- Asymmetry and the inherent limits of matching a normal side.
- Altered sensation, numbness or weakness in the operated area.
- Contracture, which may need release procedures later.
- Final assessment is made at 6–12 months, and longer in growing children.
When to Seek Care
- A flap or graft that turns dark, cold, black or stops bleeding when pricked.
- Fever above 38 °C, or spreading redness, warmth or discharge around a wound.
- New or worsening pain, swelling or fluid leakage from the operative site.
- Bleeding that does not stop with gentle pressure.
- Any change in a reconstructed area that concerns you, however minor.
References & Further Reading
- American Society of Plastic Surgeons (ASPS) — reconstructive surgery guidance
- World Health Organization (WHO) — burn and trauma care resources
- Chinese Medical Association, Plastic Surgery Branch — clinical guidance
- Cochrane Library — systematic reviews in wound and reconstructive care
This page is patient education, not medical advice, and it does not cite individual studies. Discuss your own case with a qualified clinician. To arrange an assessment at Chongqing West District Hospital, see Contact & Consultation.