The main reason for the lack of support of Mohs for invasive melanoma is that one of the aims of the excision is to remove the dermal lymphatics where the tumor can spread down and metastasize to the regional lymph nodes. The current guidelines put forth by the NCCN recommend margins to include the dermal lymphatics, Dr. Gabriel says, with the goal of preventing local recurrence and detecting possible satellite or in-transit disease.
“A primary goal of the excision is to prevent a local recurrence,” he adds.
Navigating through the different closure techniques and choosing the most appropriate procedure for the individual case can be challenging. In the end, however, Dr. Gabriel says the choice of closure technique will heavily depend on personal preference of the patient and the training of the clinician.
Skin grafts are very attractive because it is an immediate closure; however, the aesthetic outcome may be less than optimal due to the resulting permanent depression, which is an aspect that Dr. Gabriel says many patients do not immediately recognize.
“Closure through secondary intention, particularly over boney surfaces may be more cumbersome for patients, because they have to be followed up more frequently, but the final cosmetic results may be better than skin graft outcomes,” Dr. Gabriel says.