Living in sunny Southern California has many benefits. Unfortunately for those of us who habitually sun bathe (naturally or via tanning salons) or through constant sun exposure, the risk of skin cancer also increases.
I am presenting a case of a female with biopsy proven squamous cell carcinoma on the back of the head (kudos to the dermatologist for picking it up!). Due to the large size (4 cm before excision), it is best to perform the excision in serial fashion until all the margins are clear. The options are Moh’s surgery or excision with frozen section. During Moh’s surgery (which is usually done in the dermatologist office under local anesthesia), the dermatologist removes the lesion and then removes small strips of skin around the lesion. With each removal, the dermatologist (who specializes in Moh’s surgery) examines the margins under the microscope, until all the margins are clear of cancer. Excision with frozen section is similar, in that the lesion and a 2mm rim of skin is excised with the lesion. The pathologist then freezes the tissue and examines it for any involved margins. In this case, to be on the safe side, even though the margins were clear, the pathologist recommended removal of an additional 2mm rim of skin for permanent examination (permanent is more accurate than frozen section). The final size of the lesion after complete excision was 6cm in width.
The dermatologist had referred this patient to me knowing closing a large lesion such as this will be challenging. To close such a large defect requires raising a large scalp flap. The patient is shown one month post surgery and the scar is barely noticeable. There is no sign of recurrence and the hair is growing normally.
It is important to note, even with clear margins, there is a 3% chance of recurrence. Therefore, the patient will require follow-up for recurrence and for new skin cancer development.
Michael A. Jazayeri, M.D. is a board certified plastic surgeon with over 13 years of experience. His office is located in Orange County, California. To schedule a complimentary consultation, please call (714) 834-0101.
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