Departments of Plastic and Reconstructive Surgery, Amsterdam, the Netherlands.
Surgical Oncology at the Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands.
J Plast Reconstr Aesthet Surg. 2021 Jun;74(6):1303-1308. doi: 10.1016/j.bjps.2020.12.078. Epub 2021 Jan 8.
Split-thickness skin grafts are often applied in the management of primary cutaneous melanoma. It is routine surgical practice to use the contralateral limb because of the alleged risk of donor site metastases that may occur when the ipsilateral limb is used. The rationale and clinical evidence for this routine were assessed in light of current understanding of pathways of metastasis of melanoma. We found the preference for the contralateral limb to go back to Paget's ideas on melanoma spread from 1889, and the clinical observation of five cases of split-thickness skin graft donor site metastases in a series of 226 tumours, published in 1962. We traced ten additional reported cases of melanoma metastases occurring in the skin graft donor site. Contralateral donor sites were involved in seven of these cases. In light of current knowledge, the occurrence and the location of any split skin donor site metastasis are to be considered as mere indicators of an aggressive course of systemic disease. Any location of a split skin donor site, whether ipsilateral or contralateral in relation to the primary tumour, may become the location of metastases but chances that such metastases occur are extremely rare. Because of the lack of evidence in favour of the use of the contralateral limb and because of sound considerations in favour of using the ipsilateral limb, we conclude that there is no objective argument to sustain the dogmatic ban of the ipsilateral limb as a donor site for a split-thickness skin graft in melanoma surgery.
中厚皮片移植常应用于原发性皮肤黑色素瘤的治疗。由于同侧肢体使用时可能发生供区转移的所谓风险，因此常规使用对侧肢体。鉴于目前对黑色素瘤转移途径的理解，评估了这种常规做法的原理和临床证据。我们发现，从佩吉特（Paget）1889 年提出的黑色素瘤扩散观点，以及 1962 年发表的 226 例肿瘤系列中 5 例中厚皮片供区转移的临床观察，都可以看出人们对偏好对侧肢体的原因。我们追踪了另外 10 例报道的黑色素瘤转移发生在皮片供区的病例。在这些病例中，有 7 例涉及对侧供区。根据目前的知识，任何中厚皮片供区转移的发生和位置都应被视为全身性疾病侵袭性病程的单纯指标。任何中厚皮片供区的位置，无论是同侧还是对侧与原发性肿瘤相关，都可能成为转移的位置，但发生这种转移的可能性极小。由于缺乏支持使用对侧肢体的证据，并且由于使用同侧肢体的合理考虑，我们得出结论，没有客观论据支持将同侧肢体作为黑色素瘤手术中中厚皮片移植的供区的教条式禁令。
