Case 20 2026: Staged Excision and Delayed Primary Closure of a large Nodular Basal Cell Carcinoma of the Anterior Scalp

Mikkel Halborg Sørensen; Nanja Gotland Sundstrup; Christian Lyngsaa Lang

Journal of Plastic, Breast & Reconstructive Surgery·Fagfællebedømte kirurgiske case-rapporter med åben adgangFagfællebedømt · Open access

Case 20 2026: Staged Excision and Delayed Primary Closure of a large Nodular Basal Cell Carcinoma of the Anterior Scalp · JPBRS

Case-rapport

Case 20 2026: Staged Excision and Delayed Primary Closure of a large Nodular Basal Cell Carcinoma of the Anterior Scalp

Mikkel Halborg Sørensen¹, Nanja Gotland Sundstrup¹, Christian Lyngsaa Lang¹

¹Department of Plastic Surgery and Burns, Rigshospitalet, Copenhagen University Hos-pital, Denmark

Publiceret 28. maj 2026285 visninger6 min læsning

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Resumé

A 48-year-old woman was referred with a non-radically excised nodular basal cell carcinoma of the anterior scalp complicated by wound infection and dehiscence. Re-excision with 3 mm margins to the galea was performed under local anesthesia. Given local inflammation and uncertain margin status, delayed reconstruction was planned pending histopathological confirmation. After clear margins were verified, controlled subgaleal undermining allowed tension-reduced primary closure. This staged strategy ensured oncologic safety while preserving hair-bearing scalp and avoiding unnecessary flap reconstruction. Patient medical history A 48-year-old woman was referred after incomplete excision of a nodular basal cell carcinoma (nBCC) of the anterior scalp performed in private plastic surgery practice. Histology demonstrated tumor involvement of the lateral margins, while the deep margin was free of tumor. Postoperatively, wound rupture and infection developed. Microbiology showed sparse growth of Staphylococcus aureus, and antibiotic therapy was initiated. The patient was otherwise non-smoking and healthy, with well-treated asthma, as her only relevant comorbidity. Before and After Patient examination Clinical examination revealed a 22 × 19 mm anterior scalp defect with limited perifocal erythema and minimal purulent discharge. No regional lymphadenopathy was palpable. Pre-operative considerations Initial histopathology demonstrated nodular basal cell carcinoma with focal lateral margin involvement and a clear deep margin, without perineural invasion or other high-risk features. In accordance with current recommendations for low-risk BCC, re-excision with 3 mm c

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Pearls

• In incompletely excised scalp BCC, staged reconstruction enhances oncologic safety.
• Subgaleal undermining is the principal mobilization plane in scalp closure.
• Excision to galeal level improves deep margin control.
• Mattress sutures facilitate tension redistribution and reduce focal ischemia.
• Closure planning must account for both tension vectors and hair orientation.

Pitfalls

• Immediate flap reconstruction prior to margin confirmation may compromise oncologic management.
• Excessive undermining may jeopardize vascularity.
• High-tension closure increases risk of dehiscence and alopecia.
• Neglecting hair direction may result in suboptimal cosmetic outcomes.

Patient history

A 48-year-old woman was referred after incomplete excision of a nodular basal cell carcinoma (nBCC) of the anterior scalp performed in private plastic surgery practice. Histology demonstrated tumor involvement of the lateral margins, while the deep margin was free of tumor. Postoperatively, wound rupture and infection developed. Microbiology showed sparse growth of Staphylococcus aureus, and antibiotic therapy was initiated. The patient was otherwise non-smoking and healthy, with well-treated asthma, as her only relevant comorbidity.

Examination

Clinical examination revealed a 22 × 19 mm anterior scalp defect with limited perifocal erythema and minimal purulent discharge. No regional lymphadenopathy was palpable.

Pre-operative considerations

Initial histopathology demonstrated nodular basal cell carcinoma with focal lateral margin involvement and a clear deep margin, without perineural invasion or other high-risk features. In accordance with current recommendations for low-risk BCC, re-excision with 3 mm clinical margins to the galeal level was planned to achieve oncologic clearance1. Intraoperative frozen section was considered, as margin assessment is often performed prior to flap reconstruction to ensure radical excision before tissue rearrangement. However, given the anticipated large circumferential extent of the scalp excision, frozen analysis would have permitted only partial peripheral sampling and was therefore unlikely to substantially increase oncologic certainty or alter the operative strategy. Definitive paraffin histology was deemed sufficient.
The scalp consists of five layers: the skin (epidermis and dermis), subcutis, galea aponeurotica, loose areolar plane, and pericranium. Due to firm adherence between skin and galea, intrinsic elasticity is limited. Tissue recruitment depends primarily on subgaleal undermining. However, excessive undermining or flap design in previously inflamed tissue increases vascular risk and may create additional alopecic scars.2 In the present case, reconstruction was further complicated by recent infection, local inflammation and uncertain tumor clearance.
For these reasons, delayed closure was intentionally chosen from the outset. Although a local rotation (ying-yang) flap and also skin grafting was considered as reconstructive options, definitive flap reconstruction was deferred until histologic clearance was confirmed. Immediate flap transfer in a field with uncertain margins risks oncologic compromise and unnecessary tissue rearrangement if further re-excision is required.
During the postoperative period and after confirmation of clear margins, progressive tissue relaxation occurred following the initial high-tension wound closure and partial wound dehiscence. This resulted in increased scalp mobility, which allowed renewed subgaleal undermining and ultimately enabled delayed primary closure at the second procedure, thereby avoiding skin grafting or flap reconstruction. Achieving a tension-free closure was prioritized, as excessive wound tension in the scalp is associated with scar widening and secondary alopecia due to mechanical stress and vascular compromise of hair-bearing skin. A rotation (yin–yang) flap was therefore not required. Avoiding flap transposition preserved native hair-bearing scalp, minimized additional scarring, and reduced overall reconstructive morbidity.
Closure orientation was selected to balance biomechanical tension redistribution with preservation of the anterior hairline contour. On the anterior scalp, scar visibility is influenced not only by classical Langer’s lines but also by hair direction and follicular orientation.3

Referencer

Gulleth Y, Goldberg N, Silverman RP, Gastman BR. What is the best surgical margin for a Basal cell carcinoma: a meta-analysis of the literature PRS. 2010 oct.; 126 (4):1222-31
Leedy JE, Janis JE, Rohrich RJ. Reconstruction of acquired scalp defects: an algorithmic approach. Plastic and Reconstructive Surgery. 2005;116(4):54e–72e. DOI: 10.1097/01.prs.0000179188.75076.9b
Beasley NJ, Gilbert RW. Scalp and forehead reconstruction. Clinics in Plastic Surgery. 2005;32(2):203–215. DOI: 10.1016/j.cps.2004.11.002