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There are few things more frustrating for a skin surgeon than a pathology report—from a wide excision that required a complex reconstruction—detailing multiple positive surgical margins.

A 68-year-old woman with a history of multiple skin cancers presented with a large asymmetric pigmented lesion on the cheek. It had very irregular borders, a range of colors from light brown to black, and had apparently slowly increased in size over a few years (Figs. 16.1 and 16.2).


A highly atypical pigmented lesion on the cheek.


Dermatoscopic examination confirmed a highly atypical lesion. There is a pseudo network, asymmetric pigmented follicular openings, and white scar-like areas.

A deep incisional biopsy was performed. Histologic examination confirmed melanoma in situ, lentigo maligna (LM) type, extending to the radial margins. No dermal invasion was identified.

A routine wide local excision (WLE) was performed with a 5-mm margin around the clinically visible tumor (Fig. 16.3). Routine histopathology showed LM in this excision, extending to within 2 mm of the radial margin in the sections examined. Somewhat surprisingly, a further re-excision revealed small foci of residual LM extending to within 1.25 mm of a radial margin.


After the diagnosis had been confirmed with the biopsy, a 5-mm-minimum radial margin was drawn around the identified tumor.

Finally, a further excision with 5-mm margins was performed and this was found to be negative for malignancy (Fig. 16.4). The workflow of this case is outlined in Table 16.1.


Two further excisions were required before adequate margins were achieved histopathologically, resulting in a large defect.

TABLE 16.1Workflow of Illustrated Case

The scenario illustrated in this case is not too uncommon when dealing with LM of the face. This patient was subjected to four separate surgical procedures. Each was performed on different days over several weeks while the pathology was being processed and examined, and the next surgical procedure was booked only once the pathology report was received in the surgeon’s office.

LM is well known to extend histopathologically much further than is appreciated clinically or dermatoscopically. To ensure that the illustrated LM had been completely excised with the first excision attempt, an excision with up to 15-mm margins (around the visible lesion) would have been needed. The ...

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