Reconstruction after wide excision of the nail apparatus for in situ or minimally invasive subungual melanoma: A retrospective case series.

INTRODUCTION

Historically, subungual melanoma (SUM) was treated by amputation of the affected digit. Wide local excision (WLE) of the nail apparatus has since become a conservative alternative for in situ or minimally invasive lesions. While several reconstructive techniques have been described after WLE, few centers have reported their outcomes objectively. This study presents our series of reconstructions following WLE of the nail apparatus.

METHODS

We conducted a retrospective study at a university hospital, including patients referred by dermatologists for WLE and nail apparatus reconstruction between 2021 and 2024. Clinical, surgical, functional, and aesthetic outcomes were evaluated using validated scores (QuickDASH, Modified Mayo Wrist Score, AOFAS).

RESULTS

Ten patients were included. Reconstructions were performed with full-thickness skin grafts (n = 6), with or without dermal matrix (n = 4), and local flaps (n = 4). Five patients underwent immediate definitive reconstruction. Two recurrences occurred: one requiring dermal matrix removal, and the other necessitated amputation forinvasive SUM. Functional and aesthetic outcomes were satisfactory, with a mean follow-up of 19 months and no local recurrence in the remaining patients. The mean QuickDASH score was 25.5 ± 16.4 (range: 2.3-41). For the three foot cases, the mean AOFAS score was 86 ± 4.1 (range: 80-90).

CONCLUSION

Nail apparatus reconstruction is feasible for in situ or minimally invasive SUM, particularly when the Breslow thickness is ≤0.5 mm. In invasive cases, immediate reconstruction risks being performed over residual tumor, supporting a two-stage approach, especially when donor site morbidity is expected. Techniques such as full-thickness skin grafts combined with a dermal matrix provide reliable functional and aesthetic outcomes. A two-stage approach is particularly valuable when oncologic margins are uncertain, as it reduces the risk of reconstructing over residual disease while preserving options with lower donor-site morbidity.