Reconstruction After Wide Excision of the Nail Apparatus in the Treatment of Melanoma

Background: /Objectives: Historically, the treatment of subungual melanoma (SUM) was based on amputation of the affected digit. However, extended wide local excision of nail apparatus (WLE) is now a conservative alternative for in situ or minimally invasive forms. There are many after WLE reconstruction techniques, but few studies have objectively compared their results. The objectives were to carry out a systematic review of after WLE reconstructions in the treatment of SUM and to present a series of cases operated on with objective evaluation. Methods: This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations. An exhaustive search was carried out in the PubMed (Medline), Embase and Cochrane Library databases, from their creation to January 2025. Articles reporting reconstructions after WLE for SUM of the fingers or toes were included. Clinical, technical and outcome data were analyzed. A retrospective study of ten cases operated on between 2021 and 2024 was carried out, with clinical, surgical, functional and aesthetic data collected, as well as validated scores (Quick DASH, Modified Mayo Wrist Score, AOFAS). Results The literature review included 24 articles on 373 patients, mostly with in situ SUM. Reconstruction was most often performed using total skin grafts, sometimes combined with dermal matrices. Some authors used local or free flaps. Few studies used validated functional scores. Local recurrences were significant, affecting 18% of patients and requiring secondary amputation. In our series, all patients underwent WLE with reconstruction, using total skin grafts with or without dermal matrix, or local flaps. There were two recurrences. The functional and aesthetic results were satisfactory and objectively measured, with an average follow-up of 19 months. Conclusion: Nail apparatus reconstructions are primarily indicated for in situ or minimally invasive subungual melanomas. Immediate reconstruction carries a risk of performing the reconstruction over residual tumor tissue, particularly in the case of invasive melanomas. Reconstructive techniques, such as full-thickness skin grafts and the use of dermal matrices, can provide satisfactory functional and aesthetic outcomes. However, objective evaluations of these results remain limited, and better standardization of clinical practice, along with prospective studies, is needed to refine long-term outcome assessment.