Scientific Abstract Presentations: Reconstructive Session 4 Friday, October 10 Fri, Oct 10 5:00-6:00 p.m. CDT

PURPOSE – Given the complexity of microsurgical reconstruction, understanding reimbursement patterns is essential for fair compensation and equitable access to care for patients requiring advanced reconstruction. This study aims to perform a comprehensive financial analysis comparing reimbursement trends in head and neck (H&N) flap reconstruction versus deep inferior artery perforator (DIEP) flap breast reconstruction. METHODS – A retrospective review identified all patients undergoing H&N or DIEP flap microsurgical reconstruction at a single institution from 2016 to 2023. Demographics, peri-operative details, complications, payer status, and reimbursement data were collected. Descriptive and t-test analyses were used for statistical analysis.
RESULTS – A total of 136 H&N and 140 DIEP flap patients were reviewed. Providers received $4,322 more per patient and $7.19 more per operative minute for DIEP versus H&N flaps ($7,272 ± 5,003 vs. H&N: $2,950 ± 2,161; p<.0001). Medicaid reimbursement percentage greatly favored DIEP flaps (53.4% vs. H&N: 29.9%; p=.0034). Operative time was similar (DIEP: 569.8 ± 108.7 min vs. H&N: 546.7 ± 142.1 min; p=.133). Hospitals were reimbursed $32,337 more per H&N patient, a 7.7-day longer length of stay likely contributed (p<.0001). CONCLUSIONS – This analysis highlights disparities in reimbursement for microsurgery, revealing undervaluation of H&N free flaps compared to breast microsurgery, which received higher compensation and Medicaid reimbursement despite comparable operative times and technical demands. Efforts toward transparent financial policies are needed to achieve fair reimbursement and delivery of equitable care.

Introduction: The latissimus dorsi muscle (LDM) is widely used in reconstructive surgery due to its large surface area, reliable vascular supply, and versatility. It plays a crucial role in shoulder stability, adduction, internal rotation, and scapular control. While donor-site morbidity following LDM harvest has been extensively studied in adults, data in pediatric patients remain limited. Given the ongoing musculoskeletal development in children, concerns exist regarding long-term functional outcomes, compensatory adaptations, and potential postural alterations. This study evaluates long-term donor-site morbidity, shoulder function, and musculoskeletal adaptation in pediatric patients undergoing free LDM transfer. Methods: A retrospective review was conducted on pediatric patients who underwent free LDM transfer for soft tissue reconstruction between 2018 and 2021 at a tertiary care center. All procedures were performed by a single senior surgeon. Patients aged ≤17 years (males) or ≤15 years (females) were included. Donor-site morbidity was assessed using the Disabilities of the Arm, Shoulder, and Hand (DASH) score, Shoulder Pain and Disability Index (SPADI), and Pediatric American Shoulder and Elbow Surgeons (Pedia-ASES) assessment. Functional outcomes included range of motion, shoulder stability, ability to perform daily activities, and spinal asymmetry. Results: A total of 21 pediatric patients (12 males, 9 females; mean age: 7.0 ± 4.1 years, range: 1–15 years) were included. Trauma was the leading indication for reconstruction (n=19). Flaps were categorized as muscle-only (n=9), myocutaneous (n=11), or myofascial (n=1). The average flap size measured 121 ± 38 cm². The anterior tibial artery and vein served as the primary recipient vessels in 10 cases, while the superficial temporal artery and vein were utilized in 5 cases. Functional assessments indicated minimal donor-site morbidity and excellent postoperative outcomes. The mean DASH score was 7.49 ± 5.62, reflecting low disability. SPADI pain and disability scores were 5.72 ± 3.89 and 4.17 ± 4.01, respectively, further supporting favorable functional recovery. The mean Pedia-ASES score of 42 ± 18.6 demonstrated largely preserved shoulder function. Patients were followed for an average of 37.3 ± 11.5 months, during which no instances of major shoulder instability, scapular dyskinesia, or progressive spinal asymmetry were observed. Importantly, all patients regained full range of motion and were able to resume their normal activities without limitations. These findings suggest that compensatory mechanisms, particularly by the deltoid, supraspinatus, and pectoralis major, effectively mitigate functional deficits following LDM harvest. Conclusion: Free latissimus dorsi muscle transfer in pediatric patients is associated with minimal long-term donor-site morbidity and excellent functional recovery. Despite the LDM's critical role in shoulder biomechanics, children demonstrated significant adaptive muscle compensation, likely due to ongoing musculoskeletal plasticity. While concerns regarding spinal stability and postural changes remain, no significant abnormalities were observed in this cohort. Given the limited data on donor-site morbidity in pediatric patients, further research should investigate long-term biomechanical adaptations, function-sparing surgical techniques, and extended follow-up to refine reconstructive strategies in children.

Introduction

Limb salvage remains the primary goal following severe extremity trauma, yet some patients ultimately undergo amputation [1]. Indications for amputation after attempted salvage include orthopedic or vascular complications, soft tissue deficiency, infections, or functional limitations. This study aims to characterize the indications, timing, and factors associated with amputation after attempted limb salvage to optimize patient selection, improve surgical decision-making, and set realistic expectations for long-term outcomes [2].

Methods

A retrospective analysis of patients undergoing lower extremity limb salvage over 30 years at a high-volume trauma center was performed. Student's t-test, Chi square tests, and Fisher's exact tests were utilized to identify univariate differences. Bivariate and multivariable logistic regression identified predictors of amputation, with key variables including vascular consultation, number of debridements, reconstruction timing, and free flap use.

Results

Of 253 lower extremity limb salvage patients, 33 (14%) ultimately underwent major amputation. Amputations ≤3 months after attempted salvage represented 42% (n=14). Of these, 13 were attributable to the soft tissue envelope: eight due to failure of tissue transfer and five due to progression of injury-related necrosis. 57% (n=19) of amputations occurred >3 months after attempted salvage, attributable to recalcitrant bone/hardware infection 53%, (n=10), inability to achieve a stable soft tissue envelope (21%,n=4), or sequelae of traumatized limb (26%,n=5) including chronic pain or recurrent ulceration.

Amputation was associated with suspected vascular injury (OR=2.7, p=0.048) and free flap use (OR=6.2, p=0.022). Larger free flaps showed stronger association with amputation (latissimus dorsi, OR=7.01, p=0.0158; ALT, OR=14.03, p=0.0033), while smaller flaps were not associated with amputation (vastus, p=0.0837; MSAP p=0.9981). Reconstruction performed within 8-10 days of injury was associated with lower risk of amputation (OR=0.06, p=0.0287). Sub-cohort analysis of patients who underwent early versus late amputation found female sex (OR=13.5, p=0.025), latissimus free flap (OR=5.04, p=0.034), soft tissue coverage failure (OR=5, p=0.039), and acute injury severity (OR = 10, p=0.049) were significantly associated with early amputation.

Conclusion

Determining relative benefit of limb salvage versus primary amputation for patients with limb-threatening trauma continues to be a primary challenge of surgical management. Compared to late amputations, early amputation was significantly associated with proxies of higher injury severity: vascular injury, larger flaps, flap loss, necrosis beyond flap coverage, and later reconstruction timing. Patients with viable reconstructions who later required amputation were disproportionately female and those struggling with bone/hardware infections. These findings help multidisciplinary limb salvage teams better counsel patients on likelihood of amputation as an outcome and improve understanding of what elements of injury severity may predict failure of limb salvage. Future studies should focus on refining decision-making algorithms to better predict salvageability, optimize surgical timing, and reducing the need for secondary amputation while also providing patients with expectations regarding limb salvage versus amputation.

Citations:

[1] Piwnica-Worms W, Stranix JT, Othman S, et al. Risk Factors for Lower Extremity Amputation Following Attempted Free Flap Limb Salvage. J Reconstr Microsurg. 2020;36(7):528-533. doi:10.1055/s-0040-1710358

[2] Bosse MJ, MacKenzie EJ, Kellam JF, et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med. 2002;347(24):1924-1931. doi:10.1056/NEJMoa012604

Purpose The internal mammary artery and vein (IMA/V) are the most commonly used recipient vessels for deep inferior epigastric artery perforator (DIEP) flap breast and chest wall reconstruction (1). Complex cases, such as extensive cancer involvement, previous radiotherapy, scarring, and inflammation, may compromise the IMA/V, and alternative vessels must be urgently considered. This case series aims to evaluate the use of the thoracoacromial artery and vein (TAA/V) as recipient vessels for breast and chest wall reconstruction.

Methods Three patients were retrospectively reviewed who underwent DIEP flap chest wall and breast reconstruction using the TAA/V. Surgical exposure of the TAA/V involved elevation of the pectoralis major muscle and identifying the course of the vessels along the undersurface of the muscle. A small counter incision may be required just below the lateral third of the clavicle to expose the vessels. With knowledge of the vessel course, the pectoralis major muscle can be divided directly over the TAA/V. The cephalic vein in the deltopectoral groove can also be exposed as additional venous outflow.

Results In all patients the TAA/V was identified and utilized without requiring microvascular revision. The TAA diameter was 1.5-2 mm, and the TAV was 2-4 mm. Three patient examples are reviewed. Patient 1 presented with a large central chest wound with numerous rib fractures and osteomyelitis. Patient 2 presented for delayed breast reconstruction with a history of breast cancer without radiation therapy. Patient 3 presented for breast reconstruction with a history of breast cancer, radiation therapy, a previously failed latissimus dorsi flap due to infection, and severe pectus excavatum. All flaps survived, with only patient 3 experiencing a small area of skin necrosis.

Conclusion Extensive chest wall and breast defects can compromise the use of the internal mammary recipient vessels for free flap reconstruction. The thoracoacromial vessels serve as reliable alternative recipient vessels in this setting. Exposure does not require a position change and can be rapidly utilized as recipient vessels without the need for additional rib resections. Cosmetically, a remote incision resembles a portacath incision and offers good cosmesis in the breast cancer population. The proximity of the cephalic vein offers an additional venous outflow system. This study highlights the utility of these vessels and offers an anatomic review of the vessel location and tips for their exposure.

References: 1. Darcy CM, Smit JM, Audolfsson T, Acosta R. Surgical technique: The intercostal space approach to the internal mammary vessels in 463 microvascular breast reconstructions. J Plast Reconstr Aesthet Surg. 2011;64(1):58-62. doi:10.1016/j.bjps.2010.03.003

Introduction: Multiple simultaneous free flap reconstructions for extensive head and neck defects in vessel-depleted necks are extremely challenging. The "Orochi" flap, described by Koshima, in which one or more secondary free flaps are anastomosed to the main pedicle of a primary free flap resulting in a fabricated chimeric flap may be a useful option when recipient vessels are scarce.

Methods: Orochi free flap reconstructions for head and neck defects from 2005 to 2024 were reviewed. Postoperative outcomes for Orochi flaps were compared to outcomes for traditional free flaps and vein grafted free flaps using multivariate regression and propensity score matching.

Results: Seventy-two Orochi flaps were compared to 385 traditional flaps, and 47 vein grafted flaps. The flap loss rate was 0% for primary Orochi flaps and 4% for secondary Orochi flaps. Only vein grafted flaps (OR= 68.7 (95% CI: 2.6-1788.6)) and history of prior free flaps (OR = 44.2 (95% CI:2.2-879.4)) were found to be independent predictors of total flap loss on multiple regression analysis. In propensity score matched analysis, Orochi flaps had shorter median hospital stays (8 vs. 10 days, p <0.05), and vein-grafted flaps had higher rates of overall complications (21% vs. 8.3%, p = 0.037) and total flap loss (7.1% vs. 0%, p = 0.035) compared to traditional flaps.

Conclusions: Orochi flaps are a reliable option for head and neck reconstruction requiring multiple simultaneous free flaps in patients with vessel-depleted necks, possibly offering an advantage over vein grafting to reach recipient vessels at distant sites.

Introduction: Major lower extremity amputation (MLEA) is often necessary for patients with severe dysvascular conditions, extensive tissue loss, or non-salvageable infections. Through-knee amputation (TKA) is an underutilized MLEA technique that provides advantages in weight-bearing and counterbalance for wheelchair mobility. However, post-amputation neuropathic pain remains a significant barrier to recovery, with up to 85% of amputees experiencing phantom limb pain (PLP) or residual limb pain (RLP), leading to prolonged opioid dependence. Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) have emerged as promising strategies to mitigate neuropathic pain by providing physiologic targets for severed peripheral nerves. This study evaluates the impact of surgical nerve intervention on pain management and opioid dependence in TKA patients with severe disease burden. Methods: A retrospective analysis of all TKA with peripheral nerve modification procedures performed at a single medical center between 2018 and 2024 was conducted. Inclusion criteria included patients who underwent TKA with primary TMR, RPNI, or end-to-end nerve coaptation. Patients with planned above-knee conversion or inadequate follow-up were excluded. Data collected included demographics, comorbidities, operative details, complications, pain scores, and medication usage at 1, 3, 6, and 12 months postoperatively. Trends in morphine milligram equivalents (MME) and neuroleptic (pregabalin) dosages were analyzed over 12 months. Results: A total of 36 TKAs were performed in 32 patients with a mean age of 69.7 years. The most common indications for TKA were dysvascular ischemia (41.7%) and infection (38.9%). Comorbidities were prevalent, with 66.7% of patients having diabetes, 55.6% having peripheral vascular disease, and a mean charlson comorbidity index (CCI) of 6.6. TMR was performed in 72.2% of cases, while RPNI and end-to-end coaptation were performed in 13.9% each. The median postoperative hospital stay was 11 days. Complications were observed in 8.3% of patients, including stump infection (2.8%) and dehiscence (5.6%). Neuroma-related revision surgery occurred in 5.7% of cases. Among patients initially ambulatory, 55.6% were fitted for a prosthesis, and 55.0% of those achieved ambulation, with a median time to prosthesis of 3.6 months and ambulation of 4.4 months. The overall mortality rate was 36.1%, with a median time to mortality of 7.2 months. Pain outcomes demonstrated a reduction in residual limb and phantom pain over time, with 63.9% of patients reporting no pain at final follow-up. Narcotic consumption decreased over time, with 16.7% of patients using opioids at a mean follow-up of 7.9 months, compared to 50.0% at 1-month postoperatively. Mean MME also declined from 66.8 at 1-month follow-up to 45.0 at final follow-up. Pregabalin use followed a similar trend, decreasing from a mean of 148.0 at baseline to 57.3 mg at final follow-up. Conclusion: TMR and RPNI demonstrate promise as palliative interventions for neuropathic pain in TKA patients with high disease burden. By addressing post-amputation pain at its root cause, these techniques offer a non-pharmacologic alternative to traditional pain management strategies. Future studies should further evaluate their role in optimizing palliative care pathways for this highly comorbid and medically complex patient population.

Background Sacrocolpopexy addresses pelvic organ prolapse symptoms including urinary incontinence, discomfort, and bulging. The technique anchors the apex of the vagina to the sacrum to support the prolapsed vagina. Traditionally, this support is achieved using a synthetic mesh sling. However, many patients prefer to avoid prosthetic mesh given its relatively high rates of exposure and extrusion. Autologous fascial grafts can be viable solutions to mesh with improved durability and decreased morbidity. This case series documents the use of the anterior abdominal rectus fascia for sacrocolpopexy with concomitant abdominoplasty-style complex closure.

Cases & Technique A 53-year-old female (Figure 1) presented for robotic fascial sacrocolpopexy in the setting of pelvic floor dysfunction secondary to prior robotic myomectomy. Another 53-year-old female (Figure 2) presented with recurrent vaginal prolapse refractory to mesh-based sacrocolpopexy. Both operations began with a low transverse abdominal incision and pre-fascial dissection to the xiphoid. Anterior left and right rectus fascial grafts (~25x6 cm) were then sharply harvested, and the fascia was closed to the midline. The gynecology team then completed the robotic fascial sacrocolpopexy; existing incision and dissection were used for port access for this robotic assisted part of the operation. Following this portion, plastic surgery returned for complex closure of the abdomen over drains with absorbable sutures after the soft tissue was redraped over the repaired abdominal wall and trimmed. Both patients had an uncomplicated recovery with a short inpatient stay to monitor for return of bowel function. In follow-up, there was evidence of improved pelvic prolapse symptoms.

Discussion The rectus abdominis fascia represents an optimal graft due to its large size, strength, and availability. This autologous tissue eliminates the need for implantation of potentially problematic pelvic mesh, avoiding the complications of mesh extrusion and exposure. The rectus fascia is also useful in the repair of failed previous sacrocolpopexy with synthetic mesh, and this technique is being offered in our institution for these revision surgeries and for primary procedures. Interdisciplinary collaboration between plastic surgery and gynecology facilitates an efficient harvest of the rectus fascia while allowing for concomitant abdominoplasty-adjacent closure techniques with redundant skin removal. Access to the useful rectus fascia donor site necessitates a large incision warranting complex closure with improved abdominal contour. This approach results in the dual benefit in patients who present with pelvic organ prolapse and abdominal tissue and skin laxity, with prolapse repair and a beneficial aesthetic result. This two-team operation does lengthen surgical duration and recovery with a larger incision site and potential donor site complications such as herniation, hematoma, or infection. While the outcomes for our current patients are promising with improved prolapse symptoms, long term follow-up of the rectus fascial graft durability will be needed to determine its utility. Future research should aim to evaluate patient satisfaction, complications, and long-term outcomes comparing autologous tissue grafts to synthetic mesh as well as satisfaction related to abdominoplasty-style closure techniques.

Conclusion Interdisciplinary collaboration between plastic surgery and gynecology on abdominal rectus fascial sacrocolpopexy addresses patients' pelvic prolapse with the additional aesthetic benefits of abdominoplasty.

Background: Medial arterial calcification (MAC) is emerging as a tool to predict adverse limb events, but its impacts on microsurgery is unknown. This study evaluates the impact of MAC on microsurgical outcomes in a cohort of patients undergoing limb salvage.

Methods: Patients receiving lower extremity free tissue transfer (FTT) from 2011 to 2024 were reviewed. Radiographs were used to classify patients into absent, moderate, or severe MAC categories using the validated scoring by Ferraresi et al. Endpoints included (1) major lower extremity amputation (MLEA), (2) unscheduled surgical reinterventions, (3) postoperative revascularization, (4) major adverse limb events (MALE), defined as a composite of MLEA or surgical reintervention, and (5) survival.

Results: Among 320 cases, 12 (3.8%) had moderate and 32 (10.0%) had severe MAC. Median follow-up was 22.2 months. On univariate analysis, patients with moderate and severe MAC demonstrated a significantly higher rates of flap complications (absent: 25.7% vs. moderate: 33.3% vs. severe: 56.3%; p=0.033), MALE (42.0% vs. 75.0% vs. 84.4%; p<0.001), surgical re-intervention (absent: 41.3% vs. 66.7% vs. 81.3%; p<0.001), postoperative vascular intervention (6.9% vs. 8.3% vs. 31.3%; p<0.001), MLEA (12.0% vs. 25.0% vs. 31.3%; p=0.009), and 5-Year mortality (5.4% vs. 8.3% vs. 18.8%; p<0.001). On multivariate analysis, severe MAC independently increased odds of MALE (p=0.009) and unscheduled reintervention (p=0.015).

Conclusion: While microsurgical FTT can achieve limb salvage in patients with severe MAC, it is associated with significant morbidity, as over 80% will require additional surgical management. Microsurgeons should be made aware of MAC and its association with adverse events.

Background: Scar outcomes are traditionally evaluated at 12 months post-surgery, yet early prediction may enable timely interventions and improve patient expectations. This study evaluates the predictive value of 3-month scar assessments for 12-month outcomes using validated patient-reported and objective measures.

Methods: A prospective cohort of 40 surgical patients underwent scar evaluations at 3 and 12 months using the SCAR-Q and an adapted Patient and Observer Scar Assessment Scale (POSAS). Logistic regression assessed the predictive accuracy of 3-month "good" vs. "bad" scar ratings for 12-month classifications. Linear regression models evaluated the predictive relationships for continuous scar variables (vascularity, width, height, depth, and overall opinion). Predictive accuracy was assessed using area under the receiver operating characteristic curve (AUC) and correlation coefficients.

Results: Scars predicted as "good" at 3 months were 69.1 times more likely to remain "good" at 12 months (p < 0.001), with a model accuracy of 87.5% (95% CI: 73.2%–95.8%), sensitivity of 95.8%, and specificity of 75.0%. The ROC AUC of 0.854 confirmed strong predictive performance. The false negative rate was 4.2%, and the false positive rate was 25.0%. Linear regression showed strong correlations between 3-month and 12-month scar characteristics. Overall opinion was highly predictive (β = 1.092, p < 0.001, R² = 0.53, r = 0.731). Scar depth showed the strongest association (β = 0.961, p < 0.001, R² = 0.75, r = 0.870), explaining 75.1% of variance. Scar width (β = 0.772, p < 0.001, R² = 0.38, r = 0.619) and scar height (β = 1.393, p < 0.001, R² = 0.36, r = 0.602) also demonstrated moderate predictive accuracy. Vascularity at 3 months did not predict 12-month outcomes (r = -0.080, p = 0.623, R² = 0.006), highlighting its variability over time. Pigmentation predictions were 87.5% accurate, though poorly healing scars showed greater unpredictability.

Conclusions: Early scar assessments at 3 months reliably predict 12-month outcomes, particularly for depth, overall opinion, width, and height. Good scars rarely worsen, while bad scars show minimal improvement, supporting early prognostication in clinical practice. These findings emphasize the predictive utility of early scar assessments, enabling evidence-based treatment strategies and patient counseling.

Background: The surgical treatment of melanoma, including excision and reconstruction, can be performed by a variety of surgical specialties and through a multidisciplinary approach (1,2,3). Tumor location, size, and depth can impact specialty selection and reconstructive approach. Although dermatologists and ophthalmologists also play major roles in management, we sought to specifically understand the differences in treatment types and complications between patients treated by plastic and reconstructive surgery (PRS), otolaryngology (ENT), and general surgery (GS), the surgical subspecialties that frequently manage complex excisional and reconstructive procedures. Identifying optimal reconstruction strategies can improve outcomes and enhance patient care.

Methods: Melanoma cases from 2009 to 2022 were identified in the National Surgical Quality Improvement Program (NSQIP) database. Patients who underwent wide local excision, with or without reconstruction, were categorized by surgeon specialty and anatomic location. Data analysis included demographics, clinical characteristics, and complication rates with univariate and multivariate regression.

Results: A total of 10,495 patients were identified who underwent WLE with a mean age of 68.5 ± 14.2 years. The majority were male and white (62.3% and 75.5%, respectively). Among all patients, 4,555 (43.4%) underwent reconstruction. GS performed the greatest percentage of total reconstructive procedures (36.3%), followed by PRS (34.2%), ENT (24.4%), and other specialties (5.1%).

By location, head and neck melanomas were primarily reconstructed by PRS (48.8%) and ENT (37.9%). Trunk melanomas were mostly managed by GS (72.2%). Extremity melanomas were treated by PRS (33.8%) and GS (32.2%).

Reconstruction techniques varied by specialty. While PRS and GS used proportionately more skin grafts (48.6% and 66.7% of their reconstructions, respectively), and ENT more local flaps (38.9%) and free flaps (31.2%), PRS performed the greatest number of free flaps overall. By anatomic site, split-thickness skin grafts were most common for head and neck (36.0%), while full-thickness grafts predominated for extremities (52.6%).

Superficial SSI rates were highest in ENT cases (4.2%), which primarily comprised head and neck reconstructions. Deep SSI was most common in GS cases (1.0%, p=0.009), which predominantly comprised trunk and extremity reconstructions. Inpatient status increased organ/space SSI risk by 5.82x (p<0.001), and emergency cases had a 5.28x higher risk (p=0.012). Smoking, congestive heart failure, and steroid use predicted superficial SSI (p<0.05). Multivariate analysis showed extremity reconstructions had 1.38x higher odds of superficial SSI (p=0.03) and 1.5x higher odds of organ/space SSI (p=0.04) compared to head and neck reconstructions.

Conclusion: Melanoma reconstruction varies by site, with specialties favoring different techniques. Specialty selection and reconstruction choices influence complication risks. Patient health factors also impact outcomes, highlighting the importance of interventions such as smoking cessation and steroid tapering. This study provides insights into how specialty-driven reconstructive techniques affect melanoma outcomes, aiding treatment optimization and patient care.

1. Santamaria-Barria, J. A., & Mammen, J. M. V. (2022). Surgical management of melanoma: Advances and updates. Current Oncology Reports, 24, 1425--1432.
2. Nosrati, A., et al. (2017). Outcomes of melanoma in situ treated with Mohs micrographic surgery compared with wide local excision. JAMA Dermatology, 153, 436--441.
3. American Cancer Society. (n.d.). Treating melanoma skin cancer. Retrieved from https://www.cancer.org/cancer/types/melanoma-skin-cancer/treating.html