Acral melanoma: considerations about the surgical management of this tumor

Acral melanoma (AM) is a subtype of cutaneous melanoma, which is found on the soles of the feet, palms of the hands, and subungual areas. It presents a lentiginous growth pattern and is more frequent in darker-skinned populations, including Africans, Asians, and Latin Americans. Despite its indolent behavior, AM has a poor prognosis, often because it is diagnosed at a more advanced stage, which makes dermatological training about this tumor very important. The treatment of AM is based on surgical removal of the tumor. The excision challenges the surgeon, since it frequently results in large surgical defects that are difficult to reconstruct. The best surgical technique for the affected areas should achieve good functional and cosmetic results, with a short healing time and a low rate of complications. We present two cases that illustrate what we have observed in a reference center in São Paulo. A female patient, 49 years old, had AM excised and reconstructed with full-thickness skin graft (FTSG). The patient evolved with partial loss of the graft and intense local hyperchromia all over the graft attachment site (Fig. 1). The second case refers to a male patient, 60 years old, diagnosed with AM. Secondary intention healing (SIH) was preferred after excision. There were no complications, with a complete cosmetic and functional healing 12 weeks after surgery (Figs. 2 and 3). Clinically, AM appears as macules or nodules in the acral skin, and may present variations in color from brown to black and irregular borders. On the other hand, amelanotic lesions present pinkish-red macules or nodules that are often difficult to diagnose. Similar to other melanoma subtypes, their prognosis is determined mainly by their Breslow thickness at diagnosis, and then a wide surgical excision should be performed with an appropriate margin, including the subcutaneous fat. After surgery, the wound can be repaired using several methods, such as primary closure, SIH, local and free flaps, and FTSG. In addition, the exact location of the lesion, comorbidities, age, and lifestyle of the patient should all be considered when repairing foot lesions. Surgical defects on soles of the feet are difficult to repair due to the extreme lack of tissue mobility in this area. Besides, due to the characteristic lentiginous growth of the tumor associated with the safety margin, surgical defects following AM surgeries can rarely be repaired with primary closure, thus requiring the use of more complex techniques. Although skin grafts have been frequently used for acral reconstructions, intense blackening during the healing process is frequent, which makes the use of such a technique inadequate not only for esthetic reasons but also for clinical