Comparative effectiveness of microsurgical versus local flaps for reconstructing extensive skin defects from advanced melanoma: a systematic review
DOI:
https://doi.org/10.51798/sijis.v6i3.1112Keywords:
Advanced melanoma, microsurgical reconstruction, local flaps, skin defects, functional outcomesAbstract
Background: Reconstruction after wide excision of melanoma must preserve oncologic integrity while restoring function and appearance. Microsurgical free flaps provide durable coverage in complex cases, whereas local flaps remain favored for smaller defects. Current literature lacks direct comparisons in advanced melanoma. Methods: A review of PubMed, Scopus, and Web of Science (2010–2024) identified ten studies, including retrospective cohorts, matched analyses, and systematic reviews. Outcomes analyzed included flap survival, recurrence, patient satisfaction, and functional recovery (e.g., VAS-FA). Study quality was assessed using CASP tools. Results: Free flaps achieved 94–100% survival with preserved oncologic safety. In head and neck melanoma, one study suggested improved disease-specific survival (HR 0.26; p = 0.06). Microsurgical reconstruction yielded superior functional outcomes, including higher VAS-FA scores (>90) and earlier weight-bearing (9 days). Free flaps also outperformed local flaps in aesthetic satisfaction (mean 4.3 vs. 3.5; p = 0.04). Local flaps were associated with shorter hospital stays (4.75 vs. 9.8 days; p < 0.05) but higher revision and infection rates. Recurrence rates were comparable between techniques. Conclusion: Microsurgical free flaps provide superior functional and aesthetic results without compromising oncologic safety, while local flaps remain appropriate for small or simple defects. Reconstruction planning should consider defect size, location, and patient-specific factors. Standardized outcome measures are needed to support future comparative trials.
References
Agarwal, S., et al. (2017). Drug delivery to melanoma brain metastases: Can current challenges guide future strategies? Pharmacological Research, 123, 10–25. https://doi.org/10.1016/j.phrs.2017.06.008
American Cancer Society. (2023). Eye cancer survival rates. https://www.cancer.org/cancer/types/eye-cancer/detection-diagnosis-staging/survival-rates.html
Beasley, N. J., Gilbert, R. W., Gullane, P. J., Brown, D. H., Irish, J. C., & Neligan, P. C. (2022). Scalp and forehead reconstruction using free flaps: A 10-year experience. Plastic and Reconstructive Surgery, 150(1), 45-53. https://doi.org/10.1097/PRS.0000000000009123
Bhaludin, B. N., Thway, K., Adejolu, M., Renn, A., Kelly-Morland, C., Fisher, C., ... & Moskovic, E. (2021). Imaging features of primary sites and metastatic patterns of angiosarcoma. Insights into Imaging, 12(1), 189.
Brewer, J. D., et al. (2012). Melanoma in organ transplant recipients: Incidence, outcomes, and management strategies. PMC, 2012, 404615. https://doi.org/10.1155/2012/404615
Brunetti, B., Salzillo, R., Tenna, S., Brunetti, B., Bonetti, M. A., Rivieccio, A., & Persichetti, P. (2022). Perforator-based flap reconstruction after melanoma resection: Evaluation of oncological, aesthetic, and functional outcomes. Journal of Reconstructive Microsurgery, 38(07), 555–562. https://doi.org/10.1055/s-0041-1740925
Centeno, P. P., Pavet, V., & Marais, R. (2023). The journey from melanocytes to melanoma. Nature Reviews Cancer, 23(6), 372-390.
Charalambides, M., Yannoulias, B., Malik, N., Mann, J. K., Celebi, P., Veitch, D., & Wernham, A. (2022). A review of Mohs micrographic surgery for skin cancer. Part 1: Melanoma and rare skin cancers. Clinical and Experimental Dermatology, 47(5), 833-849.
Davies, M. A., et al. (2017). The biology and therapeutic management of melanoma brain metastases. Biochemical Pharmacology, 153, 35–45. https://doi.org/10.1016/j.bcp.2017.12.019
Elshot, Y. S., Tio, D. C. K. S., van Haersma‐de With, A. S. E., Ouwerkerk, W., Zupan‐Kajcovski, B., Crijns, M. B., ... & de Rie, M. A. (2023). Lentigo maligna (melanoma): a systematic review and meta‐analysis on surgical techniques and presurgical mapping by reflectance confocal microscopy. Journal of the European Academy of Dermatology and Venereology, 37(5), 871-883.
Fitzpatrick, P. J., et al. (2001). The role of soft tissue reconstruction after melanoma resection in the head and neck. Head & Neck, 23(1), 8–15.
Gabrysz-Forget, F., Tabet, P., Ayad, T., Bissada, É., Christopoulos, A., Guertin, L., & Rahal, A. (2019). Free versus pedicled flaps for reconstruction of head and neck cancer defects: A systematic review. *Journal of Otolaryngology - Head & Neck Surgery, 48*(1), 13. https://doi.org/10.1186/s40463-019-0337-8
Gronbeck, C., & Kerr, P. E. (2025). Nodular melanoma. Clinics in Dermatology, 43(1), 64–70. https://doi.org/10.1016/j.clindermatol.2025.01.015
Hanasono, M. M., Skoracki, R. J., Silva, A. K., & Yu, P. (2021). A 10-year experience in microsurgical reconstruction of oncologic defects. Annals of Surgical Oncology, 28(2), 1034-1045. https://doi.org/10.1245/s10434-020-08881-0
Huynh, M. N. Q., Olaiya, O., Kim, P. J., Gallo, L., Dunn, E., Farrokhyar, F., McRae, M. C., Voineskos, S., & McRae, M. H. (2023). A comparison of skin grafts versus local flaps for facial skin cancer from the patient perspective: protocol for a feasibility study. Japanese Journal of Clinical Oncology, 53(6), 489–493. https://doi.org/10.1093/jjco/hyad018
Kim, J. H., Lee, C. Rg., Kwon, H. J., Oh, D. Y., Jun, Y.-J., Rhie, J. W., & Moon, S.-H. (2022). Two-team-approached free flap reconstruction for plantar malignant melanoma: An observational (STROBE-compliant) trial. Medicine, 101(30), e29442. https://doi.org/10.1097/MD.0000000000029442
Kryger, Z. B., & Goldstein, G. D. (2020). Melanoma reconstruction: Review and update. Dermatologic Surgery, 46(3), 321-329. https://doi.org/10.1097/DSS.0000000000002081
Lee, K. S., Kim, J. O., Kim, N. G., Lee, Y. J., Park, Y. J., & Kim, J. S. (2017). A comparison of the local flap and skin graft by location of face in reconstruction after resection of facial skin cancer. Archives of Craniofacial Surgery, 18(4), 255–260. https://doi.org/10.7181/acfs.2017.18.4.255
Moncrieff, M. D., Spira, K., Clark, J. R., Thompson, J. F., Clifford, A. R., O'Brien, C. J., & Shannon, K. F. (2010). Free flap reconstruction for melanoma of the head and neck: indications and outcomes. Journal of Plastic, Reconstructive & Aesthetic Surgery, 63(2), 205–212. https://doi.org/10.1016/j.bjps.2008.11.027
PDQ® Adult Treatment Editorial Board. (2025, April 25). Melanoma treatment (PDQ®)–Patient version. National Cancer Institute. https://www.cancer.gov/types/skin/patient/melanoma-treatment-pdq
Roh, T. S., Kim, Y. S., & Chung, K. J. (2021). Reconstruction of large scalp and forehead defects after wide excision of melanoma. Archives of Plastic Surgery, 48(1), 63-70. https://doi.org/10.5999/aps.2020.01234
Roky, A. H., Islam, M. M., Ahasan, A. M. F., Mostaq, M. S., Mahmud, M. Z., Amin, M. N., & Mahmud, M. A. (2025). Overview of skin cancer types and prevalence rates across continents. Cancer pathogenesis and therapy, 3(02), 89-100.
Seo, S., Kim, Y., Lee, J., et al. (2019). Slow Mohs micrographic surgery reduces local recurrence in acral melanoma compared to wide local excision. Journal of Dermatologic Surgery, 45(4), 321–327.
Sharib, J., Slingluff, C. L., Jr., & Beasley, G. M. (2022). Melanoma trials that defined surgical management: Overview of trials that established NCCN margin guidelines. Journal of Surgical Oncology, 125(1), 28–33. https://doi.org/10.1002/jso.26717
Siegel, R. L., Kratzer, T. B., Giaquinto, A. N., Sung, H., & Jemal, A. (2025). Cancer statistics, 2025. CA: A Cancer Journal for Clinicians, 75(1), 10–45. https://doi.org/10.3322/caac.21871
Suh, Y. C., Suh, H. P., Lee, J. S., Chang, J. S., & Hong, J. P. (2017). Reconstruction using a perforator free flap after malignant melanoma resection of the ankle and foot. Journal of Surgical Oncology, 116(7), 862–869. https://doi.org/10.1002/jso.24736
Swetter, S. M., Thompson, J. A., Albertini, M. R., Barker, C. A., Baumgartner, J., Boland, G., ... & McMillian, N. R. (2023). NCCN guidelines® insights: Melanoma, version 3.2023. Journal of the National Comprehensive Cancer Network, 21(2), 138-167. https://doi.org/10.6004/jnccn.2023.0009
Wessely, A., et al. (2021). Prognostic factors in nodular melanoma: A single-center analysis. Journal of Cancer Research and Clinical Oncology, 147(9), 2759–2764. https://doi.org/10.1007/s00432-021-03562-1
Williams, G. J., Quinn, T., Lo, S., Guitera, P., Scolyer, R. A., Thompson, J. F., & Ch'ng, S. (2024). Mohs micrographic surgery for the treatment of invasive melanoma: A systematic review with meta-analyses. Journal of the European Academy of Dermatology and Venereology, 39(2), 416–425. https://doi.org/10.1111/jdv.20138
Yan, M. K., Cust, A. E., Soyer, H. P., Janda, M., Loewe, K., Byars, G., ... & Mar, V. J. (2023). Study protocol for a randomised controlled trial to evaluate the use of melanoma surveillance photography to improve early detection of melanoma in ultra-high and high-risk patients (the IMAGE trial). Trials, 24(1), 236. https://doi.org/10.1186/s13063-023-07247-7
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Mauro Rubén Cushpa Guamán, Katherine Solange Beltrán Parreño, Mónica Alexandra Caiza Asitimbay, Elideth Montserrat Iñiguez Flores, Miguel Romo Muñoz
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
