Plastic Surgery Research Council

Back to 2019 Posters


Back To Square One: Peripheral Margin Control Of Advanced Cutaneous Malignancies In A Multidisciplinary Setting
Meredith L. Grogan Moore, BS, Megan Shelton, MD, Matthew Fox, MD, Brent Egeland, MD.
Dell Medical School at the University of Texas at Austin, Austin, TX, USA.

Purpose: Achievement of disease-free margins is the primary surgical objective in management of cutaneous malignancies. Standardized guidelines for reaching negative margins, and thereby avoiding additional surgery or adjuvant radiation therapy, include wide excision or Mohs surgery. Mohs improves disease-free recurrence due to its inherent total margin evaluation, as opposed to permanent block sections evaluating only a portion of the margin. Some tumors benefit from total margin evaluation yet are too large to evaluate with Mohs and involve critical structures at the deep margin; traditional methods would create a large open wound between stages, or require lengthy immunohistochemistry (IHC). The square procedure, which consists of excising a geometrically mapped strip of skin at the presumed tumor border, plus subsequent permanent pathology techniques can achieve total margin evaluation prior to deep resection. We aimed to evaluate this technique in non-melanoma tumors. Methods: A case series of 10 non-melanoma skin cancers was prospectively identified. In each case, total margin evaluation margin was deemed critically important, yet tumor characteristics precluded Mohs. Each tumor underwent square procedure(s) under local anesthesia with en face permanent sectioning until margins were clear, followed by secondary coordinated surgical resection for deep margins and reconstruction. Inclusion criteria for this study included primary non-melanoma cutaneous malignancy, defect size precluding Mohs, need for IHC, need for coordinated resection and reconstruction, and anatomic region where open wounds would be contraindicated or would create secondary management difficulties. Each patient was followed from the square procedure through reconstruction and 1-year follow-up. Results: 10 cases met inclusion criteria. Each case was prospectively followed for a minimum of one year follow-up (maximum 5 years). The primary tumor type included 4 large (>15cm diameter) nodular and infiltrative types of basal cell carcinoma, 2 cases of microcystic adnexal carcinoma, dermatofibrosarcoma protuberans with infiltration of the calvarium, spindle cell neoplasms of the jawline and neck, and 2 soft tissue sarcomas overlying critical structures such as the lung. In each case we successfully achieved negative peripheral margin prior to deep resection in an average of 2.2 stages. Deep resection and reconstruction were then coordinated in a single stage in each case. Tumor recurrence rate was 0%. In each case the resection and reconstruction were coordinated and expedited in a single care episode.
Conclusions: Peripheral margin clearance in large aggressive tumors before en bloc resection provides advantages including a low recurrence rate, predictable timing between resection and reconstruction, reduction in higher risk/higher expense operative procedures, and facilitation of precise reconstructive planning. In addition, rates of adjuvant treatment such as radiation may be reduced. Further, with this approach the patient does not experience an intermediate large open wound requiring resource-intensive wound care, pain, or even hospitalization. The technique has become standard of care at our institution, and this novel approach should be considered in all patients with large cutaneous malignancies posing difficult margin containment.
Figure 1: Representative case.


Back to 2019 Posters