Reconstruction Options for Ear and Nose Melanoma

Abstract

The ear is not commonly involved with malignant melanoma. While about 20% of melanomas occur in the head and neck, only 3–20% involve the ear (about 1–4% of all melanomas). The prognosis is significantly better than mucosal melanoma (85%) at 5 years and (77%) at 10 years. Patients with positive sentinel lymph nodes had a worse prognosis (60%) at 3 years (Jones et al. Am J Surg. 206:307–313, 2013). “Wide local excision” was used with no recommended margins. Studies have been done to determine if melanoma in the head and neck area could have “wide local excisions” which are smaller less agressive than those recommended for the trunk and extremities. The current National Comprehensive Cancer Network (NCCN) Clinical Practice Guideline recommends 0.5 cm for in situ lesions; 1 cm for lesions >1.0 mm thick; 1–2 cm for lesions 1–2 mm thick, and 2 cm for lesions thicker than 2 mm. Rawlani et al. performed a study in which the margins were reduced by half (0.5 cm for lesions >1 mm; 0.5–1 cm for lesions 1–2 mm thick; and 1.0 cm in lesions thicker than 2 mm). They had 79 patients in the series with 42 cases with recommended margins and 37 with reduced margins. They found no statistically significant difference in survival in this fairly small sample (Rawlani et al. J Surg Oncol. 111: 795–799, 2015). “The American Academy of Dermatology” published recommendations in 2011 based on both evidence from prospective randomized control studies and consensus opinion:

• 1. Wide excision for melanoma is associated with reduced recurrence.

• 2. For thin melanomas, currently there is no high-quality evidence to support excisions of more than a 1 cm margin in improving survival or local recurrence rates.

• 3. For primary melanomas of any thickness, there is no evidence to suggest that margin excision of more than 2 cm provides any additional benefit in terms of survival or local recurrence rates.

• 4. The actual recommendations: In situ: 0.5–1 cm; >1 mm to 1 cm; 1–2 mm to 1–2 cm; >2 mm to 2 cm.

If these guidelines are followed, excision size in the face would leave defects between 1 and 4 cm in diameter. In the case of the ear such an excision would require complicated reconstruction (Jones et al. Am J Surg. 206: 307–313, 2013).

There is obviously still some controversy about the issue of margins and larger series are needed specifically for malignant melanoma of the face.

The primary treatment for melanoma involving the cheeks, forehead, scalp, and nose therefore remains somewhat controversial. The current National Comprehensive Cancer Network (NCCN) Clinical Practice Guideline recommends 0.5 cm for in situ lesions; 1 cm for lesions >1.0 mm thick; 1–2 cm for lesions 1–2 mm thick, and 2 cm for lesions thicker than 2 mm (Rawlani et al. J Surg Oncol. 111: 795–799, 2015). Other authors have studied reducing these margins when treating facial melanoma by ½ and in small series report no difference in survival (Cheriyan et al. J Surg Clin North Am. 94: 1091–1113, 2014). While an excision of 4 cm on the forehead or scalp is still a challenge, such an excision on the nose or cheek requires considerable reconstructive skills. Wide local excision, using whatever criteria are selected, should not be incompatible with a normal appearance.

This chapter will illustrate an approach to repairing defects between 1 and 4 cm in diameter in the ear and nose. Multiple options based on the availability of local and regional tissue will be discussed. The goal is to restore the patient’s appearance so that they can confidently go about their lives after excision of melanoma. Options such a skin grafts, flaps, local tissue rearrangement, and regional tissue transfers will be presented.