At the Johns Hopkins Melanoma Program, patients are offered the complete spectrum of care: from diagnosis, resection, complex reconstruction, and follow-up, all in one area, by the best trained surgeons who are at the forefront of surgical care and research. The Division of Plastic, Reconstructive and Maxillofacial Surgery has developed a world-wide reputation over the past five decades in facial and crainiofacial tumor resection and reconstruction. Its faculty are world-recognized experts and authorities in facial reconstruction doing hundreds of cases every year. Johns Hopkins has developed a comprehensive program for the management of melanoma and other complicated malignancies with particular expertise in the head and neck region.
Paul Manson, M.D.
The Division of Plastic, Reconstructive and Maxillofacial Surgery offers the highest degree of talent by some of the most experience surgeons in the world. The faculty complete more free tissue transfers than any other program in the country. Free tissue transfers are complicated techniques that use micro-surgery to reconstruct and replace tissue, both boney and soft, that has been destroyed by tumor or trauma or has been removed in the management of a tumor. Our micro-surgeons perform more than 250 free tissue transfers a year with greater than 97 percent success rate. Hopkins surgeons are Fellowship-trained in the specialized area of facial nerve reconstruction. These devastating problems can be the consequence of advanced tumors or complicated tumor management.
When analyzing the best method of reconstruction, the surgeon must evaluate the composition, appearance and function of the considered donor area. Blood supply is a concern when choosing a method as well. Poor blood circulation will result in poor healing and donor tissue acceptance. Patients who are malnutritioned or have coronary artery disease and/or diabetes heal poorly.
There are several options when considering reconstruction that vary from simple skin grafts to more complex surgeries like a distant flap.
Skin grafts are performed from either taking skin from another part of the patient’s body, or from a cadaver. The tissues can include skin, fat, bone and/or cartilage. Skin grafts are the most common from of reconstruction and are classified as either split-thickness (have less elasticity) or full-thickness (used on fingers, hands, and face). Not only does a skin graft provide ample coverage of the excised area, but it adheres and grows anywhere on the body. Tiny blood vessels connect and grow into the dermis of the graft. The pigmentation of the grafted skin slowly changes color to blend with the rest of the area. For best results there must be a good blood vessel system in place.
Flaps are tissues transplanted with their own blood supply. They are divided into three types: local, regional, and distant. Local flaps are an exact match to tissue and shape of the space it’s being used for, such as the face. Regional flaps are comprised of tissues taken from a nearby area of the melanoma and are often used to re-build large areas of vital structures including bone and nerves. Free flaps, or free tissue transfer, involves the removal of tissue from an entirely different part of the body. This procedure requires optimal blood supply and advance microvascular surgery. Although the advantages of this surgery include coverage of large defects involving the head and neck, there is a chance of total flap loss, where the tissue is rejected and dies. Currently there is a 95 to 98 percent success rate for this surgery and is considered a good option for most patients.
In the instances where there is not enough donor skin to cover the excised area, a method called tissue expansion is performed weeks in advance. Tissue expansion allows the capability of using the patients own skin for graft or flap reconstruction. This technique involves implanting and empty silicone balloon next to the area that was removed. The balloon is inflated with saline periodically to stretch the tissue and muscles until the desired size is achieved. During the expansion, nerves and blood supply are maintained. It is mostly used for harvesting tissue needed to re-build the scalp, face and torso because of the type of skin needed. Disadvantages include more than one operation and scar, as well as pain and discomfort during the expansion process.
When melanoma develops on vital parts of the body, such as eyelids, ears, and noses, special techniques are used to minimize disfigurement and preserve function. For patients who require more extensive surgery, prosthetics are available.
Special Sites: Face, Feet, Ears and Others
Johns Hopkins surgeons can offer patients a predictable outcome using a series of treatments including microsurgical nerve repair, nerve grafting and muscle transfer. The reconstruction of complicated sites such as nose, eye lid and external ear has been advanced by our surgeons over the last two decades.
With melanoma on the face, surgery should be limited and may be followed by radiation to lower the risk of recurrence. For best results of any head and neck surgery, early detection is critical. In order to preserve the senses of sight, speech, smell and taste, the excision must be accurate and paired with reconstruction. The skin on the head and neck (including eyelids, ears, mouth and scalp) are not as thick as skin on other parts of the body. Elasticity, nerves, and blood supply need to be evaluated before surgery and/or reconstruction begin.
Other special sites include fingers, toes, and the web space between them. When examining the best way to remove melanoma from fingers or toes, the surgeon should be as precise as possible to save length and function. Many times a soft-tissue excision can be performed on the finger or toe; however, some melanoma needs to be removed with whole or partial amputation. In this case, reconstruction is necessary to close the wound.
Melanomas found on the webbing between toes and fingers require extensive reconstruction. To limit disfigurement, skin grafts are usually performed. The foot is a complex appendage with more bones and nerve endings than any other part of the body. Melanomas surgically removed from the top of the foot can generally be repaired with a simple skin graft. However, lesions found on the bottom, and weight-bearing part of the foot, requires a special skin graft, which is not always as durable as it should be. Over the years surgeons have developed a specific flap, in which they use tissue from the arch of the foot and replace the missing tissue with a simple skin graft.
Taking our treatment modalities into the future, Johns Hopkins surgeons are studying the use of man-made materials for reconstruction of skin defects as encountered in the resection of melanoma.