Details of the process of margin control surgery (MCS) may seem daunting to a skin surgeon contemplating its introduction to their practice. This simple basal cell carcinoma (BCC) illustrates how straightforward the process can be. Doctors who refer out MCS cases may wish to explain the process to patients by showing them a case like this one.
An 82-year-old man was referred for MCS with a lesion on the cheek. It had grown slowly over months and had recently started to crust and bleed (Fig. 15.1). Clinically, it was thought to be a classic nodular BCC.
A slow-growing lesion on the cheek raises suspicions of BCC. Dermatoscopy helps illustrate arborizing vessels, telangiectasia, and focal ulceration.
Following the usual preoperative procedures (including discussion of the procedure and consents), the lesion was demarcated with a pen (Fig. 15.2). Dermatoscopy helped to delineate the margins radially.
The tumor was demarcated with a pen. Magnifying glasses, the zoom function on a smartphone, or a dermatoscope can aid in demarcation.
Local anesthetic was injected (Fig. 15.3).
Local anesthetic was injected. Extending the local infiltration to well beyond the tumor markings is advised since the next step, curettage, may extend well beyond the initial margin.
Curettage was performed (Fig. 15.4). The patient did not have a preoperative biopsy, so the curettage biopsy was immediately processed as a frozen section to confirm the diagnosis of BCC. The tumor extended further than expected with the curettage and a new margin was demarcated with a pen and a notch made for orientation (Fig. 15.5).
The tumor was curetted. This helps further define the margins of the tumor.
The delimitation of the margin was redrawn as the tumor extended slightly further with the curette than initially anticipated. 1-2 mm of intact epithelium is generally needed around the defect for the excision. A notch was cut for orientation.
The first level was excised (Fig. 15.6). The bevel angle was around 45°.
Following curettage and marking, the first level was excised. The bevel angle of around 45° allows for easier embedding of the specimen.
The specimen was orientated by creating a single notch. As this was a small uncomplicated lesion, a single notch was sufficient. The specimen was carefully laid out on a gauze with the notch facing a ...