Reconstruction After Wide Excision of the Nail Apparatus in the Treatment of Melanoma: A Systematic Literature Review

Background/Objectives: Historically, the treatment of subungual melanoma was based on amputation of the affected digit. However, extended wide local excision of the nail apparatus is now considered the conservative gold standard for in situ or minimally invasive forms. There are many after wide local excision reconstruction techniques, but few studies have objectively compared their results. The objectives were to carry out a systematic review of reconstruction after wide local excision reconstructions in the treatment of subungual melanoma. Methods: This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. An exhaustive search was conducted in the PubMed (Medline), Embase, and Cochrane Library databases, up to July 2025. Articles reporting reconstructions after wide local excision for subungual melanoma of the fingers or toes were included. Clinical, technical, and outcome data were analyzed. Results: The literature review comprised 24 articles on 373 patients, primarily those with in situ subungual melanoma. 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. Conclusions: 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.