The Aftermath or How to Excise Until Clear Margins

Abstract

As we have seen in the previous chapter, topographic landmarks facilitate the precise localization of tumor-positive outgrowths in the entire 3D margins. With the help of this information, the surgeon can then carry out accurate topographic resection of these areas to completely remove the tumor. In these resections it is again important to topographically mark the tissue so that any further tumor-positive areas at the incision margins can be detected. Due to the potential complexity of this procedure, tumors might have more than one outgrowth so multiple samples will be taken; it is again imperative to set up some rules for marking the individual resections (Table 4.1). First for safety reasons for these re-excisions, it is recommendable to start the incisions always at the position corresponding to 1 h earlier as the diagnosed positive outgrowth and to end 1 h later. The safety margin depends on a lot of factors which are discussed for the first excision in Chap. 8 (see Table 8.3). Most important: small in sensible locations and if single clock times positive. Larger, if a lot of clock times are positive and if too much re-operations should be avoided. In the face normally the margin width will be between 2 and 8 mm. In the depth usually one layer deeper is taken. Second it is recommendable to set the markers in a clockwise order, starting always at the position of the earliest time of the clock of the first/previous excision. If tumor outgrowths reach, e.g., in one area from 9 to 4 o’clock passing 12 o’clock (that means 9–16 o’clock), the 9 o’clock position will be the earliest. The resection starts at 8 o’clock (here the marker is set) and ends at 17 o’clock. Every independent re-excision gets an extra marker at the earliest clock time. Third it may be useful to set suture markers at the patient to mark the re-excision area or to allow later correct orientation.