Reconstructive surgeryBMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7543.710 (Published 23 March 2006) Cite this as: BMJ 2006;332:710
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We have enjoyed reading the highly informative series on wound
healing, in particular the most recent article on reconstructive surgery
. However, as basal cell carcinoma (BCC) is the commonest cancer of
humans with an estimated 60,000 occurring in the UK each year, we feel it
important to highlight a potential error. Boyce and Shokrollahi state that
3mm is a suitable margin which they typically take for the excision of
BCCs . We did not want other surgeons, especially those who are less
experienced in the management of BCCs to be left with this misconception.
Margins of 1-3mm are inadequate for BCC, even those with a small diameter
. Wolf and Zitelli using horizontal frozen sectioning (Mohs
micrographic surgery) showed that for well-defined previously untreated
BCCs on the face which measure less than 20mm in diameter, a minimum
margin of 4mm is necessary to totally eradicate the tumour in more than
95% of cases . They inspected BCCs under bright theatre lights and
palpated the BCC to define the margins and reported that 3mm margins
removed the tumour in only 85% of cases. Even for small BCCs measuring on
average 6x5mm, excision margins of 1,2 or 3mm result in positive margins
of 16%, 24% and 13%, respectively .
Of course, we accept that there may be inter-operator variability in
what constitutes 3mm. Boyce and Shokrollahi may mark out at 3mm and excise
around the outside of these markings thereby effectively taking 4mm or
more. A less experienced surgeon, perhaps concerned about the subsequent
repair of a large defect on the face, may be tempted to mark out 3mm
around a BCC and excise inside or on the marking line thereby taking a
true 3mm margin which will inevitably result in greater incomplete
excision rates. Most dermatologists in the UK follow the guidelines set
out by the British Association of Dermatologists and take 4mm around a BCC
where possible .
1. Boyce DE, Shokrollahi K. Reconstructive surgery. BMJ 2006; 332: 710-12.
2. Asadi-Kimyai A, Alam M, Goldberg L et al. Efficacy of narrow-margin
excision of well-demarcated primary facial basal cell carcinomas. J Am
Acad Dermatol 2005; 53: 464-8.
3. Wolf DJ, Zitelli JA. Surgical margins for basal cell carcinoma. Arch
Dermatol 1987; 123: 340-4.
4. Telfer NR, Colver GB, Bowers PW. Guidelines for the management of basal
cell carcinoma. Br J Dermatol 1999; 141: 415-23.
Competing interests: No competing interests