WLE is the current standard of care for localized cutaneous melanoma. For melanomas with a greater Breslow depth, surgical margins > 2.0 cm may be necessary to achieve histologically negative margins including the subcutaneous tissue down to the fascia [
6,
7,
15] which has a high risk of complications such as wound infection, necrosis, wound dehiscence, and skin grafts failure. Severe complications following WLE of melanoma are infrequent but must be appropriately managed when they do occur, especially during the COVID-19 pandemic to decrease the risk of COVID-19 infection and impaired oncology outcomes from delayed systemic cancer therapy [
11,
12]. The patients are more susceptible to coronavirus infection than individuals without melanoma or without complication as they are in an immune-suppressive state because of the malignancy and infection. Moreover, SARS-CoV-2 infection may have contributed to the aggressive growth and recurrence of these malignant tumors [
18,
19]. The closure and healing of wounds after WLE are essential for preventing potential complications such as surgical-site infections and wound dehiscence; this aspect of surgery remains a great challenge for surgeons, patients, and their relatives. Large infected wound dehiscence leaves the body especially susceptible to infection; further insults and failure to rectify the wound can lead to disastrous outcomes [
20,
21]. Elderly patients with malignant melanoma as a patient group are at greater risk of morbidity with serious postoperative wound complications following WLE of advanced melanoma and should receive special attention [
22,
23]. In our case presentation, a 90-year-old man (case 1) suffered from postsurgical wound dehiscence and necrosis in his right axel after a non-radical excision for an advanced malignant melanoma with high risk not only for local wound infection but also for potentially life-threatening septic complication and quickly local recurrence of melanoma [
24]. Thus, rapid and definitive wound closure was therefore essential. By using the modified tangent-to-circle WLE method [
25], the side-to-side closure with minimal focal tension had been successfully performed to prevent re-postsurgical wound complications during the COVID-19 pandemic.
Wound dehiscence may arise due to multiple factors including tension, wound infection, increased patient activity, wounds in high motion areas, impaired healing through chemotherapy, or systemic disease [
20‐
23]. Some of these factors can be surmised prior to surgery [
26]. We report a case of extensive wound dehiscence following WLE of melanoma in the middle of lumbar spine area (case 3) and conclude that the causes of the wound dehiscence were wound tension and poor blood circulation. Hence, we used double advanced flaps coverage due to their low failure rates [
27], and further PICO dressings were foregone as the patient had developed granulation and hard encapsulation around the wound cavity after 1 month of treatment [
28]; however, the wound surface required reduction as soon as possible to reduce risk of infection during his immunotherapy and chemotherapy [
23,
29], which should be quickly started due to his advanced melanoma (Breslow: 5.5 mm, BRAF V600-mutation and metastases in the lymph node). Any delayed treatment might cause worse oncologic outcomes and the risk of mortality. Revisional surgery should be carried out under general anesthesia (GA) due to extensive wound dehiscence in “normal” circumstance. However, due to pressure on anesthetic departments during March 2020 of the Covid-19 pandemic, there were insufficient resources for management of the wound dehiscence using general anesthesia; therefore, reconstruction with double advanced flaps was performed under local anesthesia. The pattern of the wound dehiscence in the present case could not be explained by error of technique, but cutaneous defects that are too large for primary wound closure must be addressed with grafts or flaps with the optimal design of minimal tension for closure of the defect after WLE as shown in case 2 [
29‐
33]. We report an uncommon case of wound necrosis after WLE with an STSG on the right lower leg (case 4). Application of negative pressure vacuum-assisted wound therapy after skin graft placement yields a high success rate for split-thickness skin grafts after WLE [
34]. However, this 36-year-old women demonstrated a large amount of wound fluid in the vacuum pump which required a new dressing every 3 days without signs of local ischemia or infection; the nonhealing status of the surgical wound at even 40 days status post-surgery posed great concern with high risk of exposing the patient to possibility to be infected with SARS-CoV-19 for the repeated hospital admissions in the midst of the pandemic. The only possible factor able to explain such an uncommon complication is the lymphorrhea [
35] which was identified in this case. In the present case, we could visualize the damage lymphatic vessels using blue V dye and identify lymphorrhea, which impeded the graft-adhering process to the wound site and led to the graft failure. Blue V injection has been shown to reliably map lymphatic drainage after wide local excision of cutaneous melanoma [
36]. The lymph fluid drainage site was selectively ligated [
37], and the re-STSG healing had been archived successfully prior to the patient’s immunotherapy and chemotherapy [
38].