Jejurikar Sameer S, Borschel Gregory H, Johnson Timothy M, Lowe Lori, Brown David L
New York City, N.Y.; Toronto, Ontario, Canada; and Ann Arbor, Mich. From the Department of Plastic Surgery, Manhattan Eye, Ear and Throat Hospital; Division of Plastic Surgery, Department of Surgery, University of Toronto; and Section of Plastic Surgery, Department of Surgery, and Departments of Dermatology, Otolaryngology, and Pathology, University of Michigan Health Systems.
Plast Reconstr Surg. 2007 Oct;120(5):1249-1255. doi: 10.1097/01.prs.0000279324.35616.72.
Peripheral margin control of lentigo maligna and melanoma on the head and neck can be problematic. Frozen sections are unreliable, and conventional histopathology cannot examine the entire margin. Customary treatment involves wide excision and dressing care or skin graft coverage until histopathologic evaluation is complete, as reexcision is frequently required because of positive margins. Wound contraction, donor-site morbidity, and additional procedures before reconstruction are inherent disadvantages to this approach.
After excisional biopsy of facial lentigo maligna and thin (<1 mm) lentigo maligna melanoma, peripheral margin control was performed in the office by means of excision of 2-mm-wide linear strips of skin, 5 to 10 mm from the biopsy site, combined with simple wound closure. Total margins were evaluated by means of permanent sections. Repeated margin excision was performed until clear. Definitive excision of the lesion was then performed and, with confidence of negative peripheral margins, the optimal reconstructive option was pursued immediately.
Fifty-one lesions underwent "square" peripheral margin control, with lentigo maligna melanoma present in nine lesions (average Breslow depth, 0.65 mm). Margins required for clearance of lentigo maligna and lentigo maligna melanoma averaged 1.0 and 1.3 cm, respectively. No recurrences were identified with long-term follow-up. Reconstruction using the optimal procedure was performed immediately in all cases.
Use of the square technique in the management of lentigo maligna and lentigo maligna melanoma improves the certainty of peripheral margin control before definitive excision. Immediate reconstruction can be performed, thereby avoiding temporizing procedures or open wounds and providing for optimal aesthetic and functional results.
头颈部恶性雀斑痣和黑色素瘤的切缘控制可能存在问题。冰冻切片不可靠，传统组织病理学无法检查整个切缘。常规治疗包括广泛切除和伤口护理或植皮覆盖，直至组织病理学评估完成，因为切缘阳性时经常需要再次切除。伤口收缩、供区并发症以及重建前的额外手术是这种方法固有的缺点。
在对面部恶性雀斑痣和薄型（<1mm）恶性雀斑痣黑色素瘤进行切除活检后，在诊室通过切除距活检部位5至10mm的2mm宽的线性皮肤条带并结合简单伤口闭合来进行周边切缘控制。通过永久切片评估总切缘。重复进行切缘切除直至切缘阴性。然后对病变进行确定性切除，并在确信周边切缘阴性的情况下，立即采用最佳的重建方案。
51个病变接受了“方形”周边切缘控制，其中9个病变为恶性雀斑痣黑色素瘤（平均Breslow深度为0.65mm）。恶性雀斑痣和恶性雀斑痣黑色素瘤切缘阴性所需的平均切缘分别为1.0cm和1.3cm。长期随访未发现复发。所有病例均立即采用最佳方法进行重建。
在恶性雀斑痣和恶性雀斑痣黑色素瘤的治疗中使用方形技术可提高确定性切除前周边切缘控制的确定性。可以立即进行重建，从而避免临时手术或开放性伤口，并实现最佳的美学和功能效果。
