This presentation demonstrates the technique of staged perimeter excision for lenticulmaligna in critical anatomic locations. Another term for perimeter excision is SMEX, or staged margin-controlled excision. This patient has a lenticulmaligna of her left lateral canthal region with variable hyper and hypopigmentation. Here you can see the perimeter excision removing a fairly narrow strip of skin. A map is made, the true margin inked blue, and the pentagon shape used here will result in five strips of skin for the pathologist to examine on FAS. This shows the residual moat. Because the margins are submitted for permanent section, the pathologist will be able to review the margins, free from frozen section artifact, and will be able to use immunostains if desired. While awaiting pathology, the wound can be temporarily closed, leaving the central tumor intact on the cheek, which simplifies wound care. Any positive margin can then be revised in a similar fashion, submitting a parallel strip of skin in an area of positivity, and reclosing the moat. Once the margins are clear, the central tumor can be removed, and the reconstruction completed.

staged perimeter excision

lentigo maligna

sensitive areas

immunostains

wound care