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PREOPERATIVE DIAGNOSIS: Squamous cell carcinoma of the scalp.

POSTOPERATIVE DIAGNOSIS: Same.

OPERATION PERFORMED: Radical resection of tumor of the scalp (CPT 11643). Excision of tumor from the skull with debridement of the superficial cortex with diamond bur. Advancement flap closure, with total undermined area 18 centimeters by 16 centimeters (CPT 14300).

ANESTHESIA: General endotracheal anesthesia.

INDICATIONS: This is an 81-year-old male who has a large exophytic 7cm lesion of the anterior midline scalp which is biopsy-positive for skin malignancy, specifically, squamous call carcinoma. This appears to be affixed to the underlying scalp.

PLAN: Radical resection with frozen sections to clear margins thereafter, with planned reconstruction.

CONSENT: I have discussed with the patient the possible risks of bleeding, infection, renal problems, scar formation, injury to muscle, nerves, and possible need for additional surgery with possible recurrence of the patient's carcinoma, with review of detailed informed consent with the patient, who understood, and wished to proceed.

FINDINGS: The patient had a 7cm large exophytic lesion which appeared to be invasive into the superficial table of the skull. The final periosteal margin which centrally appeared was positive for carcinoma. The final margins peripherally were all negative.

DESCRIPTION OF PROCEDURE IN DETAIL: The patient was taken to the operating room and there was placed supine on the operating room table.

General endotracheal anesthesia was administered after endotracheal tube intubation was performed by the Anesthesia Service personnel. The patient was thereafter prepped and draped in the usual sterile manner using Betadine Scrub and Betadine paint. Thereafter, the local anesthesia was injected into the area around the tumor. A **** type excision was planned down to the periosteum. A supraperiosteal radical resection was performed.

It was obvious that there was tumor at the deep margin, involving the periosteum. The edges were marked along the four quadrants, at the 12 o'clock, 3 o'clock, 6 o'clock, and the 9 o'clock positions, and these were sent for frozen section evaluation. Frozen section revealed positive margins at one end of the resection. Therefore, an additional circumferential resection was performed and the final margins were all negative.
Following completion, the deep periosteal margin was resected. The circumferential periosteal margins were noted to be negative; however, centrally, there was a small area which showed tumor eroding into the superficial cortex of the skull. Therefore, the Midas Rex drill was utilized to resect approximately 1-2 mm of the superficial cortex of the bone at the area where the positive margin was located. Healthy bone was obtained; however, it did not enter the diploic or marrow-containing bone in the area. Therefore, no bong margin was taken. However, at the end of the procedure, it did not appear that the residual bone had any residual changes consistent with carcinoma.

Following completion of the bony resection, the area was irrigated with copious amounts of saline. Thereafter, advancement flaps were created, both on the left and the right side of the scalp, with the total undermined area being approximately 18cm by 16cm. The galea was incised in multiple areas, to provide for additional mobilization of the tissue. The tissue was closed under tension with 3-0 Vicryl suture deep in the galea and surgical staples superficially.

The patient was awakened from anesthetic, was extubated and was taken to the recovery room in stable condition.

DISPOSITION: The patient was discharged to home with antibiotics and analgesics, to follow-up in approximately one week.

NOTE: The final margins of both periosteal, as well as skin were negative circumferentially, around the tumor. The only positive margin was deep, which was a periosteal margin and bone underlying it was partially resected, as was indicated above.

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