Wide Local Excision for Melanoma
Melanoma, [location], Breslow thickness [X] mm, [ulcerated / non-ulcerated], [mitotic rate X/mm2]
Same
Wide local excision, [location], [X] cm margins, with primary closure [/ advancement flap / skin graft]
[***, MD/DO]
[Resident name]
[Local with sedation / General]
Patient presents with biopsy-confirmed melanoma at [location], Breslow thickness [X] mm, [with / without] ulceration. Per NCCN 2024/2025 guidelines, [0.5-1.0 cm margins for melanoma in situ / 1.0 cm margins for Breslow <= 1.0 mm / 1.0-2.0 cm margins for Breslow 1.01-2.0 mm / 2.0 cm margins for Breslow >2.0 mm] indicated. [Sentinel lymph node biopsy planned concurrently given Breslow >= 0.8 mm / T1b features.] Risks including wound complications, local recurrence, lymphedema, and false-negative sentinel node discussed. Consent obtained.
Biopsy scar at [location] with [visible / non-visible] residual pigment. [Sentinel lymph node biopsy: [X] nodes retrieved from [axilla / groin / neck], sent for permanent pathology.] Pre-excision defect size: [X] cm. Margins: [X] cm achieved on all sides.
[SENTINEL LYMPH NODE BIOPSY, if performed:] Radiocolloid [Technetium-99m sulfur colloid] was injected [preoperatively in nuclear medicine / at start of case] around the biopsy site. Gamma probe used to map lymphatic drainage to [right axilla / left groin / neck]. [Isosulfan blue / methylene blue dye injected peritumorally.] A targeted dissection identified [X] hot and/or blue sentinel node(s); nodes sent for permanent pathology only. Frozen section was not performed.
WLE: A [0.5-1.0 cm / 1.0 cm / 1.0-2.0 cm / 2.0 cm] margin was marked circumferentially around the biopsy scar or visible lesion using a surgical marker. Pre-excision defect size measured clinically as [X] cm (used for reporting selection). An elliptical excision was designed to facilitate closure. Local anesthetic infiltrated. The excision was carried down to and including the superficial muscular fascia with [scalpel / electrocautery] (depth required for invasive melanoma per ACS CoC Standard 5.5). The specimen was oriented with sutures (short = superior, long = lateral) and sent to pathology.
Hemostasis achieved. Closure: [primary closure with [3-0 Vicryl] deep dermis and [4-0 Monocryl] skin / advancement flap / split-thickness skin graft]. Sterile dressing applied. Patient tolerated the procedure well.
None
WLE specimen to pathology with orientation sutures. [Sentinel lymph node(s) labeled individually and sent to pathology.]
Minimal
None
Patient to PACU. Discharged home.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Melanoma, ***, Breslow *** mm, [ulcerated / non-ulcerated]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Wide local excision, ***, *** cm margins, [primary closure / flap / graft]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: [Local with sedation / General]
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with biopsy-confirmed melanoma at *** (Breslow *** mm, [ulcerated / non-ulcerated]). [Concurrent SLNB planned given Breslow >= 0.8 mm / T1b features.] NCCN 2024-guided [0.5-1.0 / 1.0 / 1.0-2.0 / 2.0] cm margins indicated. Risks discussed. Informed consent obtained.
FINDINGS: Biopsy scar at *** with [visible pigment / scar only]. Pre-excision defect size *** cm. [SLNB: *** nodes from [axilla / groin] retrieved, sent to permanent pathology.] WLE margins *** cm achieved. Depth to superficial muscular fascia.
DESCRIPTION OF PROCEDURE:
[SLNB: Radiocolloid injected preoperatively in nuclear medicine. Gamma probe mapped drainage to [axilla / groin]. [Blue dye injected peritumorally.] *** hot/blue sentinel node(s) identified; sent to permanent pathology only (no frozen section).] WLE: *** cm margin marked circumferentially around biopsy scar; pre-excision defect *** cm measured clinically. Elliptical excision to superficial muscular fascia (ACS CoC Standard 5.5). Specimen oriented (short = superior, long = lateral) and sent to pathology. Hemostasis. Closure: [primary with 3-0 Vicryl deep and 4-0 Monocryl skin / flap / STSG]. Dressing applied. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: WLE to pathology (oriented). [Sentinel nodes individually labeled to pathology.]
COMPLICATIONS: None
DRAINS: None
DISPOSITION: Patient to PACU. Discharged home.
Signed: .ME, .MYDEGREE
.TODAYVariants
Head and neck melanoma
Lymphatic drainage patterns are unpredictable — SLNB with preoperative lymphoscintigraphy is critical. Facial closure often requires local flap or complex repair. Parotid involvement may require parotidectomy; bill parotidectomy code separately.
Completion lymph node dissection (CLND)
Now performed selectively following DeCOG-SLT and MSLT-II trials (no OS benefit vs. nodal observation in most patients). Document nodal yield, extracapsular extension (ECE) status, and number of positive nodes.
Desmoplastic melanoma
Pure desmoplastic melanoma (PDM) requires 2 cm surgical margins regardless of Breslow thickness due to high local recurrence with narrower margins. This exception to NCCN thickness-based margin guidance applies only to pure DM (>90% desmoplastic component); mixed desmoplastic melanoma follows standard NCCN margins. Consider adjuvant radiation for PDM after WLE given high local recurrence rate. Document histologic subtype from biopsy pathology in the operative note.
Lentigo maligna / lentigo maligna melanoma (LMM)
Lentigo maligna arises on chronically sun-damaged skin (typically face) and has unpredictable subclinical peripheral extension — standard margin marking significantly underestimates true margin needs. Staged excision ("square procedure" or "spaghetti technique") with peripheral margin mapping or staged Mohs surgery provides superior margin control and lower recurrence compared to standard WLE with 0.5 cm margins. Standard 0.5-1 cm margin for LM in situ often inadequate; many lesions require wider staged excision. Document approach used and whether definitive closure was staged.
In-transit melanoma / satellite metastases
In-transit disease (cutaneous/subcutaneous metastases between primary and regional nodal basin) is managed per NCCN based on lesion burden. Limited resectable disease (1-3 lesions): surgical excision with clear margins. Unresectable or bulky disease: intralesional T-VEC (talimogene laherparepvec, Category 1 NCCN), systemic immunotherapy (pembrolizumab, nivolumab — preferred for multiple or unresectable lesions), or isolated limb infusion/perfusion (melphalan-based; Category 2A). Radiation is Category 2B.
Subungual / digital melanoma
Subungual melanoma typically requires amputation of the involved digit at the distal phalanx (thin lesions) or proximal to the DIP/MTP joint (thicker lesions). Recent evidence supports digit-sparing surgery for in situ and selected thin subungual melanomas at experienced centers, but amputation remains standard for invasive disease. SLNB is performed for standard T-stage indications.
Charting Tips
- State Breslow thickness, ulceration, and mitotic rate (for T1 lesions) from the biopsy pathology report — these determine margin width and SLNB indication. Clark level is no longer part of AJCC 8th edition staging (removed 2018) and should not be documented as a staging element.
- Document the clinical pre-excision defect measurement (lesion + narrowest margin on each side) — this is the reporting-determining measurement. Do not derive it from the formalin-fixed specimen.
- State depth of excision: for invasive melanoma, excision must extend to and include the superficial muscular fascia (ACS CoC Standard 5.5, mandatory at accredited cancer centers). Document fascia in the note. "Deep dermis" or "subcutaneous fat" are inadequate depth for invasive disease.
- SLNB: do NOT send sentinel lymph nodes for frozen section in melanoma — frozen section compromises the specimen for serial sectioning and immunohistochemistry (S-100, HMB-45, MART-1, SOX10). Send all sentinel nodes for permanent pathology only.
- Document final surgical margin size achieved (circumferential and deep) and whether all margins are clear
- Orient specimen with sutures and communicate convention to pathology (short = superior, long = lateral is standard)
- Note sentinel node technique: tracer type, injection site, gamma probe counts, blue dye use, and number of nodes retrieved
Documentation & Reimbursement Considerations
- Report Wide Local Excision for Melanoma as the primary service when it is the definitive operation performed.
- The defect size (lesion diameter plus the narrowest margin on each side) determines the code. Measure the defect clinically at the time of surgery before excision — do NOT use the final specimen measurement, which shrinks from formalin fixation and will systematically undercode the case. Document the pre-excision clinical measurement in the operative note.
- Repair codes are separately billable in addition to excision. Simple closure is included in the excision code. Skin graft or flap reconstruction uses graft/flap codes separately.
- WLE and SLNB on the same day are not bundled; distinct-service reporting or separate-structure reporting may be required by some payers on the SLNB code when billed with WLE. SLNB should not use frozen section — see documentation tips.
- These are separate from the WLE and SLNB codes.
- 10-day global (minor): wound checks and suture removal are bundled. Re-excision for positive margins is a staged, planned procedure and uses staged-or-related-procedure reporting (staged or related procedure during postoperative period) — NOT related unplanned return-to-the-operating-room reporting. Related unplanned return-to-the-operating-room reporting is for unplanned returns to the OR for complications (bleeding, infection, dehiscence). Staged-or-related-procedure reporting resets the global period and pays at 100%; related unplanned return-to-the-operating-room reporting does not reset the global and pays only the intraoperative portion (~70-80%).